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COMMUNITY BASED NEWBORN CARE IN ETHIOPIA
Quality of CBNC programme assessment
Midline Evaluation Report March 2017
ACKNOWLEDGEMENTS
On behalf of the Federal Ministry of Health Ethiopia, the Baseline
Survey of the Community Based Newborn Care (CBNC) programme
was conducted by the IDEAS (Informed Decisions for Actions in
Maternal and Newborn Health) project, London School of Hygiene &
Tropical Medicine, and funded by the Bill & Melinda Gates Foundation.
IDEAS would like to acknowledge the assistance of the Federal Ministry
of Health, the CBNC evaluation steering committee, UNICEF, L10K,
IFHP, Save the Children and all those who collaborated with the study
team during ieldwork.
Research supervised by Dr Bilal Avan (IDEAS scientiic coordinator)
Report prepared by Dr Della Berhanu (IDEAS country coordinator)
CBNC survey coordinator: Della Berhanu (national)
JaRco lead: Tsegahun Tessema
Field coordination team: Dr Yirgalem Mekonen and
Nolawi Taddesse.
Data management team: Hana Hailu, Yordanos Hagos, Mekdes
Yeayalew and Yemisrach Okwaraji. Special thanks to Amanda Cleeve.
Data analysis: Dr Bilal Avan and Dr Della Berhanu.
IDEAS review team: Prof Joanna Schellenberg (IDEAS Principal
Investigator), Dr Elizabeth Allen and Deepthi Wickremasinghe
Coordination of publication: Rhys Williams
Design: Agnes Becker, We Are Stardust design agency
Citation: Berhanu D., Avan B.I. (2017) Community Based Newborn
Care: Quality of CBNC programme assessment - midline evaluation
report, March 2017. London: IDEAS, London School of Hygiene &
Tropical Medicine.
ISBN: 978-0-9576834-7-1
Copyright: London School of Hygiene & Tropical Medicine
CONTENTS
EXECUTIVE SUMMARY I
1. INTRODUCTION 1
Background to CBNC - 1
Scope and aim of the CBNC quality of care evaluation - 2
Early contact - 2
Case identiication - 2
Care and treatment - 2
Completion of treatment - 2
Objectives of the quality of care evaluation - 4
Organisation of the CBNC quality of care report - 4
2. METHODS 5
Study area - 5
Study participants - 5
Sampling - 6
Field operations - 8
Ethical consideration - 15
Dissemination plan - 16
3. HEALTH SYSTEM READINESS FOR
QUALITY CBNC SERVICES 17
Facility readiness for CBNC services - 17
Function of PHCUs for CBNC related services - 25
4. HEALTH SYSTEM INTEGRATION
WITHIN THE PHCU FOR QUALITY
CBNC SERVICES 43
CBNC job aids - 43
CBNC drugs supply - 45
Referral and service delivery linkage - 47
5. POTENTIAL OF HEALTH
WORKERS AND VOLENTEERS
TO DELIVER QUALITY
CBNC SERVICES 56
Training - 56
Knowledge - 59
Performance in the last three months - 69
6. MANAGEMENT OF YOUNG
INFANT ILLNESS 72
Case management - 72
VSD management - 73
VSD follow-up - 73
General counselling for healthy baby - 75
Essential skill assessment - 80
Case classiication - 82
7. DISCUSSION 86
Health system readiness to provide quality CBNC services - 87
Health system integration within the PHCU for quality CBNC service - 89
Potential of health workforce to deliver quality CBNC services - 90
Management of young infant illness - 93
RECOMMENDATIONS 95
Health system readiness to provide quality CBNC services - 95
Health system integration within PHCU for quality CBNC services - 95
Potential of health workforce to deliver quality CBNC service - 96
Management of young infant illness - 96
APPENDICES A1
Appendix I - A2
Appendix II - A3
ACRONYM DEFINITION
ANC Antenatal care
CBNC Community Based Newborn Care
HEW Health Extension Worker
HMIS Health management information system
iCCM Integrated Community Case Management
IDEAS Informed Decisions for Actions in Maternal and Newborn Health
IFHP Integrated Family Health Program
IMNCI Integrated management of newborn and childhood illness
IRT Integrated refresher training
LSHTM London School of Hygiene & Tropical Medicine
MNCH Maternal, newborn and child health
MNH Maternal and newborn health
MUAC Mid-upper arm circumference
NGO Non-governmental organisation
ORS Oral rehydration solution
PDA Personal digital assistant
PHCU Primary Health Care Unit
PNC Postnatal care
PRCM Performance Review and Clinical Mentoring
SNNP Southern Nations Nationalities and People
TTC Tetracycline
TWG Technical Working Group
VSD Very severe disease
WDA Women’s Development Army
ACRONYMS
i
This report presents results from a quality
of care assessment of the Ethiopian
Community Based Newborn Care (CBNC)
programme conducted in late 2015. It
focuses on the delivery of newborn care
and illness management services within
a community setting, primarily by health
extension workers (HEWs). CBNC is a pioneer
Ethiopian national programme, which
precedes the World Health Organization’s
policy on antibiotic use by frontline workers
for neonatal illness. The CBNC programme
quality of care assessment presented in
this report focuses on investigating facility
readiness, system integration, health
workforce potential and HEW competence to
provide quality newborn care services.
EXECUTIVE SUMMARY
BACKGROUND
The CBNC programme is a key milestone of the Ethiopian
Health Extension Program. Building on lessons learned
from integrated Community Case Management of childhood
illness (iCCM), the implementation of CBNC used the
following guiding principles to ensure rapid, high-quality
implementation: 1) government leadership and ownership;
2) spanning the continuum of care; 3) balance between
preventive and curative care at the community level; 4)
quality service; 5) community participation; 6) strong health
system support, and 7) phased implementation approach
and partnership.
The goal of the CBNC programme is to reduce newborn
mortality through strengthening the primary health care unit
(PHCU)1 approach and the Health Extension Program. This
goal is achieved by improving linkages between health centres
and health posts and the performance of Health Extension
Workers (HEWs) and Women’s Development Army (WDA), to
improve antenatal, intrapartum, postnatal and newborn care
through the “four Cs” (1) early prenatal and postnatal Contact
with the mother and newborn; (2) Case-identiication of newborns with signs of possible severe bacterial infection; (3)
Care, or treatment that is appropriate and initiated as early
as possible; and (4) Completion of a full seven-day course
of appropriate antibiotics. CBNC implementation involves
the scaling-up of community based maternal and newborn
health (MNH) services in:
1. Early identiication of pregnancy 2. Provision of focused antenatal care (ANC)
3. Promotion of institutional delivery
4. Safe and clean delivery
5. Provision of immediate newborn care, including
ii application of chlorhexidine on the cord
6. Recognition of asphyxia, initial stimulation and resuscitation
of the newborn baby
7. Prevention and management of hypothermia
8. Management of pre-term and low birth weight neonates
9. Management of neonatal sepsis and very severe disease
(VSD) at community level
COMMUNITY-BASED NEWBORN CARE
IMPLEMENTATION
CBNC was launched in March 2013 by the Government of
Ethiopia in collaboration with its implementing partners (UNICEF,
Last 10Kilometres, Integrated Family Health Program-IFHP, and
Save the Children). CBNC was implemented in two major phases.
Phase I was implemented in March 2014 in all the woredas and
PHCUs of seven selected zones from the agrarian regions namely:
Amhara (East Gojam zone), Tigray (Eastern zone), Oromia (North
and East Shewa zones) and Southern Nations Nationalities and
Peoples’ (SNNP) Region (Wolayita, Gurage and Sidama zones).
These zones were selected due to the strength of their health
system. In these seven zones a total population of over 11 million
was expected to beneit from the CBNC interventions, with 2.6 million women of reproductive age and almost 400,000 expected
deliveries per year. The CBNC programme in Ethiopia has the
following objectives:
1. To further strengthen the PHCU approach and the Health
Extension Program by improving linkages between health
centres and health posts and the performance of the HEW,
to scale up community based MNH services including
introduction of newborn sepsis management;
2. To strengthen the capacity of health centres in providing
quality maternal, newborn and child health services;
3. To further strengthen logistics and information systems
within the PHCU context;
4. To improve maternal and newborn care practices and
care seeking through the WDA and other existing efective community mobilization mechanisms; and
5. To draw experience and lessons from the initial phase to
inform the scale-up phase.
The major activities for Phase I included preparation of training
guides and supporting training materials for health workers,
HEWs and the WDA leaders, cascaded training, regional and
zonal level orientation, orientation of the WDA on CBNC,
follow-up after training and regular supportive supervision,
Performance Review and Clinical Mentoring (PRCM) meetings
and procurement and distribution of essential supplies and
drugs as well as operations research.
By August 2014 all HEWs in PHCUs in these zones had completed
training. Based on learning from the Phase I zones Phase II of
CBNC programme implementation was launched in January of
2015, with training in some zones taking place at a later date.
The London School of Hygiene & Tropical Medicine is collaborating
with the Ethiopian Federal Ministry of Health to conduct an
evaluation of Phase I, through the IDEAS (Informed Decisions
for Actions in Maternal and Newborn Health) project. Funded
by the Bill & Melinda Gates Foundation, IDEAS works with JaRco
Consulting, an Ethiopian based research agency.
CBNC EVALUATION
The objective of the CBNC Phase I evaluation is to gather,
analyse and synthesise evidence to determine whether and
how community-based newborn care in the seven Phase I
zones leads to increased coverage of critical interventions
along the continuum of care, relecting the CBNC programmatic components. The evaluation design includes before-and-
after coverage surveys of key behaviours and interventions at
household level and will compare Phase I (early implementers
of CBNC) with Phase II (late implementers of CBNC)2 areas. The
evaluation also includes a qualitative study to assess how CBNC
is being implemented (Figure i).
The CBNC baseline survey was conducted in the fourth quarter
of 20133 and the endline is tentatively scheduled to take place in
iiiFigure i. CBNC evaluation: components of CBNC Phase I evaluation
NOV 2013 NOV 2014 NOV 2015 NOV 2017
BASELINE SURVEY
Population level and facility
level coverage of key CBNC
indicators
QUALITATIVE SURVEY
How HEWs and WDA
leaders deliver the 4 Cs
MIDLINE SURVEY
Quality of care delivered
through the CBNC
programme
ENDLINE SURVEY
Change in population level
and facility level coverage
of CBNC indicators from
baseline
the fourth quarter of 2017, three-and-a-half years after the start
of CBNC implementation. The CBNC evaluation also includes
qualitative work to understand implementation processes, as
well as a midline quality of care survey. This report details the
methodology, results, discussion and recommendations that
have resulted from the CBNC quality of care survey (midline
evaluation) conducted in the fourth quarter of 2015.
CBNC MIDLINE SURVEY OBJECTIVES
The CBNC midline quality of care evaluation has the following
four main objectives:
1. To compare the health system readiness to provide quality
CBNC services in CBNC early and late implementing areas.
2. To compare the health system integration within the
PHCU for quality CBNC services in CBNC early and late
implementing areas.
3. To compare the potential of health workers and volunteers
to deliver CBNC services in CBNC early and late
implementing areas.
4. To compare the quality of care provided by HEWs including
sepsis management for infants less than two months of
age, at the health post level in CBNC early and late
implementing areas.
CBNC MIDLINE SURVEY METHODS
Like the baseline survey, the CBNC midline survey took place in
12 zones across the four regions of Ethiopia - Amhara, Oromia,
SNNP and Tigray. Data were collected over six-and–a-half weeks
from October-December 2015. Overall, the sampling procedure
for the survey resulted in a representative sample of PHCUs in the
selected zones. The midline survey compared the CBNC quality
of care between PHCUs in the seven CBNC early implementing
zones and PHCUs in the ive CBNC late implementing zones. The selection of zones for comparison was based on the Ministry of
Health’s recommendation, with the understanding that CBNC
implementation in these zones was likely to take place after the
endline survey had been conducted. However, Phase II of the
CBNC programme started in 2015. As such the midline survey
assesses CBNC programme maturity by making comparisons
iv
between areas that had a minimum of one year (average 19
months) of CBNC programme implementation and areas where
implementation had just started (average of three months) prior
to the midline survey.
The sample size calculation for the midline survey aimed to
detect a minimum 15 percentage points change in correct
classiication of young infant health status (0-2 months old) based on CBNC guidelines between early and late implementing
areas (primary outcome), with a minimum of 80% power, and
a 5% level of signiicance. This required a sample size of 420 young infants in early and 300 in late implementing areas. This
was achieved by sampling 140 health posts with three young
infants per health post in the early implementing areas, and
100 health posts with three young infants per health post in late
implementing areas. The 140 health posts in early implementing
areas were distributed across 70 PHCUs and 100 health posts
in late implementing areas were distributed across 50 PHCUs,
proportionate to the population size of the PHUCs.
This study was conducted in 30 woredas (18 in early implementing
areas and 12 in late implementing areas), 117 PHCUs (70 in early
implementing and 474 in late implementing areas) and 240 health
posts (140 in early implementing and 100 in late implementing
areas). Health facility surveys were conducted in 117 health
centres and 240 health posts to collect information on catchment
population, infrastructure, as well as CBNC-related staf proile, supervision, equipment, medicine, job aids and register review.
A total of 240 HEWs and 240 Women’s Development Army
(WDA) leaders each were also interviewed with respect to their
CBNC-related knowledge, training, supervision, mentorship
and service delivery. Lastly, the skills of all 240 HEWs to deliver
Figure ii. The four domains used to conceptualise the quality of CBNC services
MANAGEMENT OF YOUNG INFANT ILLNESS
HEALTH SYSTEM INTEGRATIONHEALTH SYSTEM READINESS
CBNC QUALITY OF CARE
POTENTIAL OF HEALTH WORKERS AND VOLUNTEERS
vquality CBNC case management were assessed through clinical
vignettes, antibiotic injection simulation and young infant clinical
case classiication. Clinical vignettes covered clinical scenarios for management of young infants with VSD, VSD follow up care and
general counselling for healthy newborns. For the clinical case
classiication, a total of 893 sick young infants of less than two months old had an observed consultation with a HEW, followed
by a re-examination by a health oicer.
This report presents the indings from the midline study with results presented by early and late implementation areas, as well
health posts to health centres.
C. Potential of health workers and volunteers to deliver quality
CBNC services (Chapter 5): Under this domain, the survey
assessed the level of CBNC programme training, knowledge
and practice among HEWs and WDA leaders. This survey
implemented a novel technique of using images from the
family health card (a maternal and child health behavioural
change communication job aid) as lash cards to assess WDA leaders’ knowledge.
D. Management of young infant illness (Chapter 6): Under
this last domain the survey assessed HEWs’ competence to
“THE QUALITY OF THE CBNC PROGRAMME HAS
BEEN CONCEPTUALISED AND ASSESSED ACROSS
FOR KEY DOMAINS.”
as totals for all the PHCUs visited. The report has seven chapters.
Chapter 1 provides a brief background on the CBNC programme
as well as an overview of the CBNC evaluation, with a focus on
the midline survey. The methodology for the midline survey is
provided in Chapter 2.
The quality of the CBNC programme has been conceptualised
and assessed across four key domains and the results of midline
survey are presented under these domains (Figure ii):
A. Health system readiness to provide quality CBNC services
(Chapter 3): Health system readiness was assessed in
terms of facility readiness (equipment, drugs and number
of trained staf). The level of supervision, mentorship and CBNC-related service delivery was also investigated.
B. Health system integration within the PHCU for quality CBNC
services (Chapter 4): Under this domain, we looked at the
drug supply chain and the supply of key job aids relevant
to CBNC, as well as at referrals of sick newborns from the
deliver CBNC services. For this purpose, novel techniques
were also employed. HEWs’ case management skills were
assessed through clinical vignettes following the CBNC
protocol. HEWs’ skills in appropriately providing gentamycin
injections were assessed through an injection model. Lastly,
HEWs’ case classiication skills were assessed although an observed consultation for a sick young infant between
the ages of 0-2 months, followed by an independent re-
examination of the newborn by a health oicer. Although the WHO health facility assessment guide does not include
case observation for 0-2 month infants, we adapted the
tools used for 2-59 month old children in accordance with
the iCCM chart booklet issued by the Ethiopian Ministry
of Health.
A discussion of the results and recommendations are detailed in
Chapter 7. There is also an Appendix of tables that show coverage
of other MNH-related indicators, some of which are not directly
tied to the management of newborn illnesses.
vi SUMMARY OF KEY MIDLINE SURVEY FINDINGS
AND DISCUSSION
Health system readiness to provide quality CBNC services
As detailed in Chapter 3, the assessment of health system
readiness to provide quality CBNC services indicated that most
facilities have the necessary equipment, supplies and job aids
to provide CBNC services. However, poor supplies of water,
soap and hand sanitizer at health posts and health centres, have
major implications for hygiene, particularly when handling a
newborn. There was a shortage of HEWs in late implementing
areas, although despite this shortage, compared with early
implementers, a greater proportion reported being available to
provide services on weekends and holidays. On average health
posts were open for ive working days, with 15% reporting that they were operational for two to four days a week.
The frequency of Performance Review and Clinical Mentoring
meetings was promising with 67% of HEWs reporting that they
had attended a meeting in the last six months. Fifty-eight percent
of HEWs (69% in early and 43% in late implementing areas,
p<0.001) reported receiving a CBNC/iCCM programme speciic supervision in the last six months. However, the most notable
gap in health system readiness was infrequent integrated
supportive supervisory visits, with 52% of HEWs (53% in early
and 50% in late implementing areas) reporting that they had
not received a visit in the last month. Furthermore, visits did not
adequately cover aspects of sick newborn care management.
Among those receiving a visit in the last six months, 53% of visits
were conducted by health centre staf, 18% by woreda health oice, 13% by an implementing partner and 15% of visits were joint (between health centre, woreda health oice and/or an implementing partner).
On the day of the survey, 97% of health posts had amoxicillin
and 91% had gentamycin. A quarter of health posts had
expired oral rehydration solution and half had expired zinc.
The level of supervision from health centre to health post has
to be strengthened to ensure that HEWs are providing services
according to the CBNC protocol and also to ensure that the
necessary drugs for the management of newborn illnesses are
available.
With respect to the function of health facilities in providing CBNC
services, there were good linkages between health posts, WDA
leaders and communities, with two-thirds of HEWs organising
monthly pregnant women’s conferences that were widely
attended by expectant mothers. Service utilisation records
showed that ANC and facility deliveries are on the rise. However,
postnatal care (PNC), particularly at health posts, was very low.
A record review of health post and health centre registers
indicated possible misclassiication of data because of the way that PNC 1 is deined by diferent health centres (PNC within the irst 24 hours of delivery prior to discharge vs after discharge). Similar problems were also evident with respect to how both
the four ANC and four PNC visits are recorded by health workers
(timing of visit vs number of visits). This indicates a conceptual
problem, highlighting a lack of clarity in the deinitions of these indicators and what they are capturing. The problem can be
addressed through training and supervision. It is important to
ensure that health centres and health posts record PNC and
ANC in a standardised manner so that accurate tracking of these
indicators can inform decisions to improve service uptake.
Health system integration within the PHCU for quality CBNC services
Chapter 4 assessed the level of system integration that exits at the
PHCU level to provide quality CBNC services. The availability of
CBNC-related drugs at health centres, for supplying health posts,
was also examined to assess the level of system integration.
Overall, 80% of health centres had some form of amoxicillin
(125 mg/250 mg dispersible tablet and/or 125mg/5ml syrup)
with no reported stock-out in the last three months. Only 2% of
health centres had amoxicillin stock-outs lasting three months
or more. In contrast, 75% of health centres had experienced
stock-out of gentamycin 20mg/2ml at some point in the previous
viithree months, with 43% having stock-out lasting three months or
more. The reason for this high level of stock-out could be because
health centres are encouraged to pass this drug to health posts
rather than retain it at their facility.
Among health centres that had received amoxicillin (125 mg and
250 mg dispersible tablets, as well as 125mg/5ml syrup) and
gentamycin (20 mg/2ml) deliveries in the last three months,
over half were provided by the woreda health oice, with this proportion being lower in early implementing areas, where
implementing partners played a greater role in providing
these drugs.
The review of the Integrated Management of Newborn and
Childhood Illness (IMNCI) register showed that 825 (378 in early
and 447 in late implementing areas) infants 0-2 months were
seen across 104 health centres in the three months preceding
the survey. The remaining 13 health centres (ive in early and eight in late implementing areas) had not recorded any cases
for the above mentioned period. Similarly, the iCCM 0-2 month
registers at health posts had recorded 428 (289 in early and 139
in late implementing areas) cases in the three months preceding
the survey. The remaining 46 health posts (13 in early and 33 in
late implementing areas) had not recorded any cases of infants
0-2 months for the preceding three months. At health post
level, among those classiied as having VSD, 46% were referred to health centres. Among the 54% that received treatment at
“THE MOST NOTABLE
GAP IN HEALTH
SYSTEM READINESS
WAS INFREQUENT
INTEGRATED
SUPPORTIVE
SUPERVISORY VISITS.”
the health post, 80% were recorded as having completed their
gentamycin injection.
Further review of registers to assess referral linkages showed
a minimal level of follow-up, with only 7% of young infants
recorded as referred in the iCCM registers at health posts being
cross-linked to IMNCI registers at the referral health centre.
The assessment of government owned vehicles for the most
recent obstetric referral showed that 63% had used woreda
health oice or health centre owned ambulances.
Potential of health workers and volunteers to deliver quality
CBNC services
The assessment of health workforce potential showed that the
majority of health centres (95%) had one or more staf members trained in IMNCI and 68% had CBNC trained staf. The high availability of IMNCI trained staf at health centres is promising. Improving the availability of staf trained both in CBNC and IMNCI will further ensure the quality of CBNC supportive supervision
and mentorship that can be provided to HEWs.
CBNC training had been scaled up in Ethiopia. In this study,
98% of HEWs (100% in early and 96% in late implementing
areas) had received CBNC training. However, a quarter of HEWs
had not attended annual Integrated Refresher Training. The
assessment of HEWs’ unprompted knowledge (without the use
of the chart booklet) showed that they had very good knowledge
on nutritional counselling and assessment. Though there were
gaps in their knowledge across newborn care and signs for
sick newborns, HEWs had good knowledge of management
and treatment for newborns with a given disease classiication. Caution should be taken when interpreting the results in the HEW
knowledge section of this report. As per government guidelines,
HEWs are not expected to memorise all danger signs. Rather they
are instructed to refer to the iCCM chart booklet.
viii The majority of WDA leaders reported having received an
orientation in newborn care in the last 12 months. Yet, like
HEWs, assessment of their knowledge showed that there were
major gaps in their unprompted knowledge on newborn danger
signs. Their comprehension of the family health card (a maternal
and child health behavioural change communication job aid),
assessed through lash cards of images depicting key messages, showed a lack of understanding among the majority of WDA
newborn. With respect to management of VSD cases, HEWs
from early implementing areas had better clinical reasoning and
management skills than those from late implementing areas.
The most striking gap was the limited skills of studied HEWs
in identifying the signs to correctly diagnose a sick newborn.
However, if HEWs were verbally informed about speciic signs of a young infant’s illness, over three-quarters were able to provide
the appropriate diagnosis and treatment for VSD. The gap in
“ALTHOUGH THERE WERE GAPS IN THEIR
KNOWLEDGE ACROSS NEWBORN CARE AND
SIGNS FOR SICK NEWBORNS, HEALTH
EXTENSION WORKERS HAD GOOD
KNOWLEDGE OF MANAGEMENT AND
TREATMENT FOR NEWBORNS WITH A GIVEN
DISEASE CLASSIFICATION.”
leaders. As the family health card serves as the key job aid for
WDA leaders to conduct their work, it is important to ensure that
their orientation covers explanations of the messages it contains.
Management of young infant illness
HEW skills for the management of CBNC related young infant
illness were evaluated through clinical vignettes, antibiotic
injection simulation and direct observation of care management
including clinical case classiication.
Clinical vignettes for VSD case management, VSD follow-up care
and general counselling for a healthy newborn showed that
overall HEWs had good patient identiication skills, although there were some minor gaps. This was similar to the indings from the 0-2 iCCM register review, which showed near complete
data on newborns’ background information. Overall, HEWs
in both early and late implementing areas were similar with
respect to their clinical skills to provide counselling for a healthy
HEW’s ability to recognise signs and symptoms for a speciic young infant’s illness highlights an area for focused training and
clinical mentorship, which can bridge the observed gap.
Assessment of HEWs’ skill in providing an intramuscular
injection of gentamycin to newborns showed that their overall
skill is low, which was surprising given their experience in
providing vaccinations. However, HEWs from early implementing
areas demonstrated better injection skills than those in late
implementing areas.
This study also conducted case classiication for 893 young infants aged 0-2 months that were considered sick by their caregivers.
The major challenge faced was the absence of caregivers
spontaneously bringing their sick young infants for treatment
at the health post. As a result, we mobilised caregivers in the
community to bringing their ‘sick’ babies, to the health post. All
young infants 0-2 months old considered sick by their caregivers
were included in this study.
ix
Comparison of the health oicers’ diagnoses to those made by HEWs showed that HEWs were able to correctly identify
young infants that did not have a particular illness, as not
having an illness. This is a promising inding as it suggests there is little misuse of antibiotics for young infant illness by
HEWs. However, HEWs from both early and late implementing
areas showed similar gaps with respect to correctly identifying
babies that presented with an illness. The clinical vignettes and
illness case classiications highlighted the areas of challenge in their theoretical and practical understanding of young infant
management. HEWs misclassiied 70% of VSD and 72% of feeding problem cases as not having these conditions. HEWs
were able to correctly identify 55% of young infants that had local
bacterial infection. Overall, two out of ive sick young infants were correctly classiied by HEWs. This indicates that some sick young infants were not receiving the appropriate life-saving drugs at the
health post level.
Data collectors spent time with HEWs the day before the sick
young infant assessment to explain the purpose and process
of the study, ensuring that they were comfortable and able to
provide services as per their routine. However, it is likely that
HEWs performance might have been diferent in the absence of the observer.
It is important to note that there are several factors afecting HEWs’ ability to correctly diagnose a sick young infant, including
opportunities to practice clinical skills, supportive supervision
and clinical mentoring. This was not assessed for in this report.
Such nuanced analysis will be part of future work.
The experience of the caregivers at health posts was very positive.
Exit-interviews showed that they were satisied with the care that was provided to them by the HEWs, which potentially reinforces
positive health seeking behaviours and sustains the demand for
community newborn care services.
Health system readiness to provide quality CBNC
services needs:
• a functional infrastructure at health post level
• CBNC essential drug supply
• supportive supervision of health post staf
• streamlined data management processes at PHCU
level, especially standardisation of the indicator
deinitions across the health system
Health system integration within the PHCU for
quality CBNC services needs:
• an intact and responsive supply chain for
CBNC antibiotics
• improved record keeping of CBNC services
• an efective referral process between health posts and health centres including transport and necessary
documentations
Potential of health workers and volunteers to deliver
quality CBNC services needs:
• regular needs assessment
• periodic refresher trainings
• optimisation of the potential of WDA leaders to
create demand for CBNC services
Efective management of young infant illness needs:
• periodic examination of HEWs’ diagnostic and
management skills
• addressing observed gaps with supervision
and mentoring
x RECOMMENDATIONS
This survey provides an overview of the quality of CBNC services
provided in early and late CBNC implementation areas. Overall,
the health system readiness to provide quality CBNC services
showed that there were good linkages within PHCUs and health
facilities were well equipped with job aids, equipment and
supplies. However, in some facilities there was an observed lack
of water and soap. Furthermore, there were stock-outs of CBNC-
related drugs at both health centres and health posts. Most
notably, there was a major gap in supervision, which heavily
limits a facility’s readiness to provide quality CBNC services. With
respect to system integration, the most notable gap was the lack
of follow-up on referrals from health posts to health centres.
Assessment of HEWs’ unprompted knowledge showed gaps in
their ability to cite newborn danger signs. Although HEWs are
not expected to memorise dangers signs, they need to know the
signs that should prompt them to refer to the chart booklet. This
was further highlighted by the clinical observations where HEWs
were unable to recognise young infants that presented with
danger signs. In clinical vignettes, once HEWs were informed
of the exact danger signs, they were able to diagnose young
infants and provide appropriate treatment. An assessment of
intramuscular injection of gentamycin by HEWs indicated that
early implementing area HEWs performed better than late
implementing area HEWs, though both groups require further
training. Despite these shortcomings, HEWs were providing
services to caregivers that left them satisied by the experience, which could potentially endorse positive health seeking
behaviour by the community for neonatal illness and create
community demand for CBNC services. WDA leaders also had
limited understanding of images included in the family health
card, with the gap being wider among late implementing area
WDA leaders.
Results from this survey can enable CBNC programme
implementers to understand the quality of services and identify
strengths and gaps, so as to direct their implementation eforts
accordingly. It is strongly recommended that the results presented
in chapters 3-6 be thoroughly reviewed to identify overall gaps in
quality, as well as gaps speciic to early and late implementation areas. Based on the indings from this midline survey, we present key recommendations below for improvement across the four
domains used to conceptualise quality CBNC service delivery:
Health system readiness to provide quality CBNC services
1. Incorporate supportive supervision activities speciic to CBNC and iCCM into routine supervision visits
2. Make provision of MNCH/CBNC-related integrated
supportive supervision for HEWs a key responsibility of
health centre staf, by including it as an indicator during their performance review
3. Increase the frequency of supervision from health centres
to health posts, ensuring that visits cover an assessment
of HEWs’ VSD service provision as well as monitoring
drugs supply
4. Improve the infrastructure, especially the water supply
5. Develop and implement a well-deined matrix for measurement of ANC and PNC through HMIS
6. Explore the possibility of integrating post-natal care
services with CBNC practices, as they are targeting the same
timeframe and closely linking them will beneit both services
Health system integration within the PHCU for quality CBNC services
1. Improve the supply chain system for CBNC related drugs,
ensuring that the drugs are fully incorporated into the
Pharmaceuticals Fund and Supply Agency and the Integrated
Pharmaceutical Logistics System
2. To ensure follow-up on referrals from the health post,
increase access to woreda ambulances for transport of sick
young infants to health centres
3. Ensure the availability of oicial referral forms at health posts and train HEWs to use them when referring sick newborns
xi
1. The primary health care unit consists of a health centre
together with the surrounding satellite health posts.
2. Areas for comparison were selected from zones where CBNC
roll-out was planned to be as late as possible, due to the need
to further strengthen the iCCM programme, PHCU linkages and
the Women’s Development Army (community volunteers) prior
to implementing CBNC.
3. Berhanu, D. Bilal, B.A. (2014) Community Based Newborn
Care: Baseline report summary, Ethiopia October 2014. London:
IDEAS London School of Hygiene & Tropical Medicine.
4. Three PHCUs in North Gondar zone (late implementing zone)
were not visited due to civil unrest. More health posts in other
PHUCs of the same zone were visited to ensure the desired
sample size.
4. Provide each sick young infant with a unique identiier for easy follow-up within the PHCU to ensure provision and
completion of treatment
Potential of health workforce to deliver quality CBNC service
1. Explore the possibility of including CBNC as part of pre-
service training to be supported by systematic on the job
mentoring
2. Ensure periodic and structured coaching by HEWs to
enhance WDA leaders’ understanding of maternal, newborn
and child health (MNCH) promotion messages spanning all
CBNC components
3. Strengthen WDA leaders’ capacity for demand creation to
increase uptake of newborn services, focusing on their ability
to recognise danger signs for young child illness and efective use of the family health card.
4. HEWs and WDA leaders’ training should incorporate their
satisfaction and engagement to inform the content and
design of future trainings
Management of young infant illness
1. Create innovative, skills based trainings and mentoring
activities for HEWs focusing on the recognition of danger
signs in young infants
2. Provide periodic refresher training to HEWs on intramuscular
injections for young infants using innovative technologies
and methods
3. To overcome limited case load of sick young infants at
the health post level, invite HEWs periodically to health
centres to observe case management skills practiced by
health oicers4. Revitalise the skills labs, especially for HEWs’ CBNC
refresher trainings
1 BACKGROUND TO CBNC
CBNC is a means of bringing life-saving care to mothers
and newborns at the community level within the Ethiopian
health system. Through CBNC, the government aims to
strengthen the primary health care unit (PHCU) and the
Health Extension Program, a platform for community-based
primary care delivery. By enhancing linkages between health
centres and health posts within the PHCU and augmenting
the performance of health extension workers (HEWs) and
the voluntary Women’s Development Army (WDA) leaders,
CBNC aims to improve antenatal, intrapartum, postnatal
and newborn care. The key components of the CBNC
programme are shown in Figure 1.
It is important to highlight that the last component is
achieved through four key steps, labeled as 4Cs: (1) early
prenatal and postnatal Contact with the mother and
newborn; (2) Case-identiication of newborns with
signs of possible severe bacterial infection; (3) Care, or
treatment that is appropriate and initiated as early as
possible; and (4) Completion of a full seven-day course
of appropriate antibiotics (Figure 2).
CBNC was launched in March 2013 by the Government of
Ethiopia in collaboration with its implementing partners
(UNICEF, Last 10 Kilometres, Integrated Family Health
Program -IFHP, and Save the Children). CBNC has been
implemented in two major phases. Phase I began in
March 2014 in seven zones across four regions of Ethiopia:
Amhara (East Gojam Zone), Oromia (North and East Shewa
zones), Southern Nations and Nationalities and Peoples’
Region (SNNP) (Wolayita, Gurage and Sidama zones) and
Tigray (Eastern zone) (Figure 3). Zones for CBNC Phase I
were selected for having a strong PHCU, health extension
program, integrated community case management
platform and WDA network. As part of a second phase of
implementation, CBNC was then rolled to other zones in the
four regions in January 2015.
1. INTRODUCTIONThis chapter provides background
information on the Community Based
Newborn Care (CBNC) programme and on
the programme evaluation.
CHAPTER SECTIONS
1. Background to CBNC
2. Scope and aim of the CBNC quality of care evaluation
3. The objective of the CBNC quality of care evaluation
4. Organisation of the midline quality of care report
2SCOPE AND AIM OF THE CBNC QUALITY OF CARE
EVALUATION
Evaluation of CBNC programme Phase I includes a baseline
(October 2013), a midline (October 2015) and an endline survey
(tentatively scheduled for October 2017). It is also supported by
qualitative research. The baseline and endline surveys assess the
change in coverage across nine components of CBNC after two-
and-a-half years of full implementation.
The rest of this report focuses on the midline evaluation, which
concentrated on quality of care in relation to the management of
neonatal sepsis or VSD at the community level through the 4Cs,
described in Figure 2 above. The survey made the comparison
between those areas that had a minimum of one year (average 19
months) of CBNC programme implementation and those where
implementation had just started (average of three months) prior
to the midline survey (Figure 3). As such, the midline assesses
CBNC programme maturity by comparing areas where CBNC had
been fully implemented for a year or more (early implementers)
to areas where the programme had just started prior to the
survey (late implementers).
The evaluation of CBNC is being carried out by Informed
Decisions for Actions in Maternal and Newborn Health (IDEAS),
London School of Hygiene and Tropical Medicine (LSHTM), UK
(Dr Bilal Avan and Dr Della Berhanu) in collaboration with JaRco
Consulting, Ethiopia (Tsegahun Tessema, Dr Yirgalem Mekonnen
and Nolawi Taddesse).
The success of the CBNC initiative on the quality of services
rests on: the continued availability of drugs and supplies, and
Figure 1. The CBNC programme components Figure 2: CBNC health care seeking framework: the 4Cs
EARLY CONTACT
with all newborns and pregnant women
through WDA leaders and HEWs
CASE IDENTIFICATION
Of newborns with signs of VSD by HEWs
and WDA leaders
CARE AND TREATMENT
Timely initiation, prescribed by HEWs
COMPLETION OF TREATMENT
Provision of a seven-day course of amoxicillin
by families and gentamycin by HEWs
and WDA leaders
Early
identiication of pregnancy
Provision of
focused antenatal
care (ANC)
Promotion of
institutional
delivery
Safe and clean
delivery
Immediate newborn
care, including
chlorhexidine
application on cord
Management of
neonatal sepsis/very
severe disease (VSD) at
the community level
Recognition of
asphyxia, initial
stimulation and
resuscitation
Management of
pre-term and low birth
weight neonates
Prevention and
management of
hypothermia
3
supportive supervision by the woreda and at the health-centre
level; the availability of skilled HEWs at health posts; and early
contact and related demand-generating activities by WDA leaders
at the community level.
The rationale for a quality-of-care-focussed midline evaluation,
one-and-a-half years after the initiation of the CBNC programme,
is to identify areas for improvement and ensure vital adjustment
and course correction in the delivery of CBNC services.
For the survey, ‘quality of care’ operationally refers to whether
HEWs correctly assess, classify, treat and refer neonatal VSD
illnesses, and provide necessary counselling to caregivers based
on CBNC and integrated Community Case Management(iCCM)
guidelines endorsed by the Ethiopian Ministry of Health.
The quality of care was assessed at both the health worker
performance level and at the level of health system readiness
and support. The assessment used the IPO (Infrastructure−Process−Outcome) framework, i.e. A. Infrastructure and commodities: adequacy of physical
infrastructure of facilities and drug supplies necessary for
CBNC delivery;
B. Service delivery processes: adequacy of trainings, supportive
supervision, referral system and HEW performance;
C. Service delivery outcome: completion of neonatal VSD
treatment and functional referral system.
For this assessment, range of data collection methodologies,
including questionnaire-based interviews, direct observation of
clinical skills, health facility observations and records reviews.
A comparative assessment was carried out in the CBNC early
Figure 3: CBNC programme evaluation areas: early implementing areas (March 2014) are in dark turquoise and late implementing areas
(January 2015) are in light turquoise.
Early implementersLate implementers
Eastern Tigray
East Gojam
North Shewa
East Shewa
Guraghe
SidamaWolayita
South Orno
East Wellega
Illubabor
North Gondor
Southern Tigray
TIGRAY
AMHARA
OROMIA
SNNP
280 Kilometres
N
0 70 140
4implementation and CBNC late implementation areas across 12
zones in the four regions, i.e. Amhara, Oromia, SNNP and Tigray.
OBJECTIVES OF THE QUALITY OF CARE EVALUATION
The evaluation had the following speciic objectives:
1. To compare the health system readiness to provide quality CBNC
services in CBNC early and late implementing areas.
The survey assessed the availability of essentials needed for the
delivery of quality services to the newborn with neonatal sepsis
or VSD. This was assessed through interviews, direct observation
of stock-outs and a review of records at the health facilities.
Supportive supervision of HEWs (health post level) for the care of
infants less than two months of age in CBNC was also assessed.
Technical and administrative supervision is imperative for the
delivery of quality newborn care services by health post staf. The nature and extent of the supportive supervision was assessed
through interviews with HEWs and the health centre staf.
2. To compare the health system integration within the PHCU for quality
CBNC services in CBNC early and late implementing areas.
This survey used interviews and direct observation to assess
drug supply chain and supply of key job aids relevant to CBNC.
Furthermore, through review of facility records for the last
quarter, the survey assessed the level of appropriate and timely
referral to a pre-designated health facility, which is one of the key
aspects of managing VSD.
3. To compare the potential of health workers and volunteers to deliver
CBNC services in CBNC early and late implementing areas.
The survey assessed the level of CBNC programme training,
knowledge and practice among HEWs and WDA leaders through
interviews and a review of records at health posts.
4. To compare the quality of care provided by HEWs including sepsis
management for infants less than two months of age, at the health post
level in CBNC early and late implementing areas.
The survey assessed the skills and practices needed for quality
delivery services to infants 0-2 months of age, including
correct classiication of the physical health of the young infant, compliance with the standard CBNC/iCCM management and
referral protocol, and facilitative interactions with caregivers
(including health education and counselling for the mother).
This objective was achieved by conducting questionnaire-based
interviews with HEWs, including the use of clinical vignettes,
observations of HEW consultations and independent re-
examination of infants 0-2 months of age.
ORGANISATION OF THE CBNC QUALITY OF
CARE REPORT
This report presents the data collected in October 2015. The
following chapter (Chapter 2), provides an overview the CBNC
midline evaluation methodology. Results are presented in
Chapters 3-6: Chapter 3 provides results on facility readiness to
provide quality CBNC services; Chapter 4 presents the level of
health system integration within in the PHCU to deliver quality
CBNC services; Chapter 5, the potential of the health worker and
volunteers to deliver quality CBNC services; and Chapter 6, the
management of newborn illnesses by HEWs. In the inal chapter (Chapter 7) we present a discussion of the study indings. Additional results not included in the body of the report are
included as appendices.
“WE EMPLOYED A WIDE
RANGE OF STANDARD
AND INNOVATIVE
DATA COLLECTION
METHODOLOGIES”
5 STUDY AREA
The CBNC early and late implementing zones were from
Amhara, Tigray, SNNP and Oromia, as shown in Table 1.
STUDY PARTICIPANTS
There were two types of participants in the study:
Health system
• HEWs performing examination and sepsis
management of infants under two months of age;
• WDA leaders from the catchment areas of health
posts;
• Health centre staf. Community
• Caregivers with infants under two months of
age who they presented at a health posts for
a consultation.
Inclusion criteria
A. Functional health post - deined as a primary care facility, which has a physical structure for provision of
health services and with at last one appointed HEW.
B. HEW - at least one HEW who has been at the health
post for the last three months. Additionally, for the
health posts in CBNC early implementation areas, one
HEW who has received CBNC training at least one year
before the time of this midline survey assessment.
C. Infant under the age of two months:
• Considered ‘sick’ by their caregivers;
• Being seen for the irst time at the health post or by either of the HEWs (including in the home/
community) for the current illness episode.
Recruitment of infants will be by:
• Infant being presented spontaneously at the
health post on the day of the survey;
• Infant actively identiied by the WDA leaders for consultation in the survey.
2. METHODSThis chapter presents the methods followed
for the CBNC midline evaluation.
CHAPTER SECTIONS
1. Study area
2. Study participants
3. Sampling
4. Field operations
5. Ethical considerations
6. Dissemination Plan
6D. WDA (1-30 network) leaders serving in their catchment areas,
who had referred a sick infant between the ages of 0-2
months in the three months or most recently preceding
the evaluation.
SAMPLING
The CBNC midline survey focused on assessing the CBNC
performance overall, and the quality of CBNC services provided
to sick young infants by HEWs at the PHCU level.
Sample size
We conducted a series of sample size calculations with varying
assumptions to ind the most eicient but feasible sample for the study. Our sample distribution of clusters was proportionate to
the population distribution in early and late implementing zones
(7:5). Table 2 summarises the best possible option considered
for the survey. In order to detect a 15 percentage point diference between early and late implementing areas and using a design
efect 2.00 and intra-class correlation of 0.5 - we found that sample size of 240 clusters (health posts) with a target of three
children (0-2 months old) selected from each health post, was
the most eicient and feasible sample size. The test statistic used is the two-sided score test (Farrington & Manning)5. Varying the
cluster number and cluster size could have made the survey less
feasible due to a) a relatively low number of health posts with
the challenge of inding more eligible young infants per health post, or b) a relatively high number of health posts requiring less
young infants per health post, but posing an enormous challenge
of extensive travelling and an extended data collection period of
more than six months. A summary of sample size estimations is
given below while more details are given in Appendix I.
Sampling strategy
The CBNC midline evaluation was carried out in all seven early
implementation zones and ive late implementation zones simultaneously across the four regions. Among the total study
population, about 60% resided in the early implementation
zones and 40% in the late implementation zones. A population-
proportionate multistage cluster sampling was employed at the
zonal and woreda levels.
Selection of woredas
There are 96 woredas in the seven CBNC early implementation
zones, and 77 woredas in ive late implementation zones. A total of 30 woredas (18 in early and 12 in late implementation
areas) were randomly selected proportionate to the zonal
population size.
Selection of PHCUs and health posts
Seventy PHUCs were selected from the CBNC early implementing
woredas and 50 PHCUs from the late implementing woredas.
Prior to data collection in a woreda, a list of all the eligible PHCUs
was compiled in collaboration with the woreda health staf. Then from the list of eligible PHCUs, the required number of PHCUs
were randomly selected. On average, we selected two health
posts within a PHCU for a total of 140 health posts from CBNC
early implementing woredas and 100 from late implementing
woredas. Where woredas did not have the required number
of PHCUs, more than two health posts were sampled form the
eligible PHCUs. As mentioned, a health post had to be functional
– a primary care facility with a physical structure for provision
of health services and with at least one appointed HEW. At
least one HEW had to have been at the health post for the last
three months. Additionally, for the health posts in CBNC early
implementing areas, at least one HEW had to have received
CBNC training at least one year before the time of the midline
survey assessment.
7
Table 2: Sample size estimation
Table 1. Areas of CBNC programme implementation in Ethiopia
ZONE WOREDA TOTAL PHCUs
CBNC early implementing areas
Oromia North Shoa 18 55
East Shoa 13 56
Amhara East Gojam 17 100
SNNP Sidama 19 112
Gurage 15 68
Wolayita 13 67
Tigray Eastern 11 35
Total 106 493
CBNC late implementing areas
I. Oromia Ilu Aba Bora 24 63
East Wellega 18 52
II. Amhara North Gondar 21 119
III. SNNP South Omo 8 29
IV. Tigray Southern 11 26
Total 82 289
EARLY IMPLEMENTERS LATE IMPLEMENTERS TO DETECT A MINIMUM
DIFFERENCE OF: No. of health posts/ no. of children
under 2 months per health post
No. of health posts/ no. of children
under 2 months per health post
70/6 50/6 15%
140/3 100/3 15%
210/2 150/2 15%
8FIELD OPERATIONS
Formative phase
Study protocol and tool development
The development of the study protocol and instrument was a
result of extensive formative ieldwork involving exploratory ield visits and iterative periodic ield testing to ensure that the tools were comprehensive and accurate, and that operational details
of data collection were attainable.
The study protocol and tools were developed by the IDEAS–
LSHTM research team, in close partnership with the ield team of JaRco Consulting, Ethiopia, which was responsible
for data collection. The research instruments strictly followed
CBNC guidelines laid down by the Ethiopian Health Ministry,
and Integrated Management of Newborn and Childhood
Illnesses (IMNCI)/iCCM assessment endorsed by the World
Health Organization.
In addition, the following new techniques were developed for
the purpose of this survey:
A. Clinical simulation to assess HEWs’ injection skills using an
injection model
B. Clinical vignette for HEWs speciically addressing CBNC programme-related illnesses
C. Young infant quality of care observation and re-examination
D. Images from the family health card (a MNH-care behavioural
change communication tool distributed by the Federal
Ministry of Health), without text, were enlarged to create
A4 laminated lash cards and were used to assess WDA leaders’ knowledge
Study protocol and tool pretesting
The near-inal versions of the protocol and tools were pre-tested in health posts in Oromia (near Addis Ababa). The ield test was an attempt to approximate actual data collection procedures and
was carried out by the study team over the course of six days.
At this point, the protocol and instruments were shared with
the Ministry of Health and CBNC implementing partners for the
inal review. The inalised instruments were translated into local languages: Amharic, Oromifa and Tirginia. Back translation into
English was carried out to ensure accuracy of the translation.
Table 3 details the midline survey instruments along with the
diferent modules included in each instrument.
CBNC midline data collection team
Field team composition
There were 12 teams in the CBNC midline survey, each with four
team members: team leader, community mobiliser, observer
and re-examiner. Team members were grouped and assigned to
speciic regions based on their language skills.
Team roles
Each member of the team had speciic roles detailed below:
1. Team leaders: mainly served as supervisors.
2. Observers: observed the HEWs’ performance (HEWs’
consultation with sick young infants, injection assessment
and clinical vignettes) and illed out the HEW questionnaire. 3. Re-examiners: conducted the health centre questionnaire
and re-examined an infant independently after the infant’s
consultation with a HEW.
4. Community mobilisers: engaged with HEWs, the kebele
command post 6 and WDA leaders about sick infants. In
addition, they conducted interviews with WDA leaders and
the entry-exit interviews with caregivers of sick babies.
In addition to these members of the team, the CBNC midline
evaluation also had a Field Coordinator and Quality Assurance
Supervisor. The Field Coordinator and Quality Assurance
Supervisor planned and oversaw the data collection and were
responsible for organising the survey, quality control and
monitoring the progress of survey teams. In addition, the Field
Coordinator was responsible for recruiting and hiring survey
personnel, and for other human resources matters.
9 Table 3: Content of CBNC midline instrument
INSTRUMENTS MODULES
1. HEW questionnaire 1. Background
2. Knowledge
3. Training received
4. Supervision received
5. Services provision
1. HEW clinical vignettes 1. VSD case management
2. VSD follow-up care
4. General counselling for healthy newborn
3. HEW injection assessment 1. Injection skill assessment
4. Observation of newborn examination by HEW 1. Interaction with caregiver and young infant
2. Physical examinations of young infant
3. General care and record keeping
4. Counselling of care taker
5. Referrals and admissions
6. Diagnosis
7. Treatment
5. Re-examination of newborn 1. Verbal inquiry
2. Physical examinations
3. Referrals and admissions by HEW
4. Diagnosis
5. Prescribed treatment
6. CBNC supplies and record review at health centre 1. PHCU information and health centre staing
2. Supportive supervision conducted
3. Facility equipment, medicines and job aids
4. Register review
5. Availability of diagnostics
7. CBNC supplies and record review at health post 1. Equipment, medicine and job aids
2. Register review
8. WDA questionnaire 1. Background
2. Knowledge
3. Orientation and materials
4. Planning meeting, practice and reporting
9. Maternal exit interview 1. Caregiver and family background information
2. Health status of young infant
3. Information provided to caregiver about illness
treatment and care
4. Referral
5. Caregiver satisfaction
10Table 4 further summarises the diferent evaluation tools along with the individual responsible for the tool and where the activity
or interview took place.
Team credentials
The majority of team leaders and community mobilisers were
identiied from the pool of data collectors that had worked with JaRco in the past. For each category of data collectors an
additional individual was trained and retained during the course
of the survey, in case data collectors dropped out.
Team leader selection
All thirteen team leaders had a master’s degree in public health
or similar ield, as well as experience in coordinating and supervising surveys.
Community mobilisers
Thirteen individuals were recruited for the community
mobilisation role. All of the selected community mobilisers had a
irst degree in diferent disciplines and had extensive experience in data collection and supervision of community based and
health facility based surveys.
Re-examiners and observers selection
The recruitment for re-examiners and observers involved
several processes. Through consultation with the Ministry of
Health’s Maternal, Child Health and Nutrition directorate and
CBNC implementing partners (UNICEF, L10K, IFHP and Save
the Children) it was agreed that government employed health
oicers trained in CBNC should hold the positions of observer and re-examiner. From the 26 individuals that met the criteria,
23 had attended a CBNC training for trainers while three had
basic training in CBNC. Observers and re-examiners were
assigned to their speciic roles based on their performance during the training and pilot testing for this survey. In the end,
there were 13 re-examiners and 13 observers. Re-examiners and
observers were assigned to woredas that were not within their
regular working area while ensuring they were able to speak the
local language.
Team training
Training for the CBNC midline survey was conducted over
eight days, three days in Addis Ababa (1-3 October, 2015) and
remaining ive days in Adama (5-9 October, 2015). Overall, the classroom training in Addis Ababa covered the study procedures,
Table 4: CBNC midline evaluation study instruments - conducted by whom and where
INSTRUMENTS RESPONSIBILITY LOCATIONS
1. HEW questionnaire, including clinical vignettes Observer Health post
2. WDA questionnaire Community mobiliser Health post
3. Identiication of eligible young infants Community mobiliser Health post
4. Observation of young infant examination by HEW Observer Health post
5. Re-examination of young infant Re-examiner Health post
6. CBNC supplies and record review at health centre Re-examiner Health centre
7. CBNC supplies and record review at health post Observer Health post
8. Maternal exit interview Community mobiliser Health post
11 the questionnaires, data-collection techniques, clinical guidelines,
quality-assurance procedures and study ethics. Speciically, the irst day involved a pre-test and review of the protocol and questionnaires related to the health centre, health post and HEW
interviews. The second and third days of the training included
covering the protocol and questionnaires according to the
speciic roles of data collectors. The training utilised both paper questionnaires and questionnaires programmed in personal
digital assistants (PDAs).
The second part of the training, conducted in Adama, pilot-tested
survey procedures and tools. This was intended to further train
the survey personnel under conditions that simulate the actual
survey. The pilot followed the exact procedures of the study to
replicate the actual data collection context, including quality
assurance measures. Adama was selected for its close proximity
to Addis Ababa and the availability of a CBNC early implementing
woreda. On day four, individuals were grouped into teams and
Data collection
A. Data collection lasted from October-December 2015. On
average, each survey ield team completed two health posts in three days.
B. Arrival at the selected woreda: the woreda was informed
of the study team’s arrival beforehand and upon arrival
woredas were provided with a copy of a permission letter
from the zonal oice. The ield team visited the woreda health oice and formally explained the purpose of the visit using a standardised formal introductory statement.
C. Data collection at the woreda health oice level: A PHCU was randomly selected in consultation with the woreda
health oice, using the predeined criteria. The person overseeing the CBNC programme at the woreda health oice communicated with the respective health centres regarding
the research team’s visit to the selected PHCUs.
D. Data-collection at the health centre level: the research team
“TWO DAYS OF DATA COLLECTION ACTIVITIES
WERE SCHEDULED AT EACH HEALTH POST”
used the ield manual to map out their speciic roles for the upcoming pilot. The pilot test took place over the course of the
three days, with each team visiting one health centre and two
health posts, strictly following the protocol to be carried out in
a given PHCU. Each day involved an afternoon feedback session
to clarify concepts and modify questionnaires, as well as discuss
challenges faced in the ield.
Day eight of the training involved discussions on data from the
pilot test, a post-test and assignment of teams to their study
woredas. Each team leader was also trained on how to compile
and upload data from PDAs onto a secure server at JaRco’s oice.
carried out two key activities in collaboration with the person
overseeing the CBNC programme within the PHCU:
• Random selection of the required number of health
posts according to the predeined criteria, and their respective HEWs were notiied of the upcoming study visits, and
• Conducting of the health centre CBNC supplies and
record review questionnaire by the re-examiner.
E. Data collection at the health post level: two days of data-
collection activities were scheduled at each health post. A
health post ield team (observer and community mobiliser) arrived at each health post before regular working hours
began (e.g. at 8:00 am). All HEWs working in the selected
health posts were asked to facilitate data-collection (e.g.
provide records). However, for the young infant examination,
12skills assessment and interview, the HEWs were selected on
the basis of length of service at the health post. The survey
ield team met with the HEWs to introduce themselves and explain the purpose of the visit (emphasising that results
would be used to assess and improve health services—not
to individually assess or ‘punish’ HEWs). The observer asked
the selected HEWs to give their consent to participate in the
study and noted this down on the interview form.
Day one at the health post
A. Community mobilisation: A list of 1 to 30 WDA leaders and their
phone numbers, obtained from HEWs, was compiled by the
community mobiliser. She/he also reviewed postnatal care
(PNC), infant immunisation and growth monitoring registers,
and prepared a list of names of women who had given birth
within two months prior to the ield team arriving at the health post. After completion of both lists, community mobilisers
called all WDA leaders to communicate to them that any
infants 0-2 months of age considered ill by their mothers
should be brought to the health post for a consultation in
the morning on the following day. Additionally, community
mobilisers attempted to meet a kebele focal person from
the command post to mobilise WDA leaders to facilitate
the identiication of eligible infants. Community mobilisers also selected WDA leaders who had recently referred a sick
newborn, and set up an appointment for an interview in the
afternoon.
B. Data collection from HEWs and WDA leaders: The observer
communicated the purpose of the study to the HEW and
made her feel at ease; she/he then conducted a HEW
questionnaire, including clinical vignettes. In the afternoon
the community mobiliser conducted a WDA questionnaire.
One HEW and WDA questionnaire were completed for each
health post.
C. Health post information: The ield team’s observer asked the HEWs to show the health post’s complete current
stock of CBNC/iCCM drugs. For stock-outs the duration
was assessed based on the HEWs’ recall. In addition, the
observer recorded their physical observations of the health
post. One health post questionnaire was completed per
health post. The observer completed the health post records
module, drawing from information recorded in the CBNC/
iCCM registers in the previous three months’ consultations
of sick infants aged 0-2 months.
Day two at the health post
A. Establishment of three data-collection stations: Each enrolled
caregiver and young infant passed through them in a given
sequence.
• Enrolment and entry-exit interview station: This was
established outside the entrance of the health post, and
was manned by the community mobilisers.
• Consultations-observation station: This was in the main
room of the health post where HEWs conduct most of
their patient consultations. The observer from the ield team was based here.
• Re-examination station: The ield team set up a folding table and chair in the storage or ANC room of the health
post for re-examination of an infant by the re-examiner.
After the re-examination, the caregiver reported back to
the irst station to complete the exit interview. B. Enrolment of young infants: As caregivers with infants arrived
at the health post, the team leader conirmed their eligibility. First, she/he was asked the age of the baby. If the age was
less than two months, the team leader asked if the infant
has any physical illness or complaints and if this was the
irst consultation with these HEWs for this illness episode. The team leader also asked the age of the caregiver and
their relationship to the infant. If the infant was eligible, a
‘caregiver and infant enrolment card’ was illed out, and the caregiver’s acceptance for participation in the study was
recorded. Additionally, the community mobiliser illed in the irst two modules (facility/infant identiiers and caregiver/family background) of the entry-exit interview.
C. Observation of the consultation: The observer silently observed
the consultation and used the observation form to record the
13 HEW’s assessment, classiication, treatment and counselling in relation to the young infant. At the end of the consultation,
if any information was unclear the observer asked the HEW:
1) what their classiication of the infant was, and 2) what treatments were given to the infant during the encounter.
One observation checklist was completed per eligible baby.
D. Infant re-examination: The re-examiner performed a
re-examination of the patient using the re-examination
form and following the Ethiopian CBNC/iCCM chart booklet.
The re-examination, was used to obtain gold-standard
classiications and treatment with which to compare the HEW’s classiications and treatment later, in the analysis. One re-examination form was completed per eligible patient.
E. Caregivers’ exit interview: Once the HEW’s consultation
and re-examination were completed, the community
mobiliser asked the caregiver about their understanding
of the medicines that were prescribed for home treatment,
when they are supposed to return for follow-up and
their satisfaction with the consultation experience at the
health post.
• Before releasing the patient, the community mobiliser
carefully checked the ‘caregiver and infant enrolment
card’ to ensure that all sections of it have been
completed. At the end, she/he thanked the caregiver
and responded to any queries they had.
• The team facilitated a referral to the nearest health
centre if any infant was observed to have a life-
threatening illness.
• All the data collection was recorded on PDAs, except
for information about the observation of the HEW
consultation, clinical vignettes and injection assessment,
which were manually recorded. At the end of day two,
the team leader reviewed all data collected at the
health post for completeness and consistency. Missing
or inconsistent data were rectiied before leaving the health post.
• Once all data-collection at the health post was
concluded, the ield team thanked the HEWs and provided any necessary feedback to them.
Data themes
The data collected provide information on the status of staf’s technical capabilities to deliver CBNC services, demand
generation activities, and the utilisation and quality of services
provided by HEWs. The data include:
A. Quality of services provided by HEWs - in terms of
adherence to standardised CBNC/iCCM guidelines
B. Training, knowledge and skills of HEWs in CBNC/iCCM
C. Availability of essential CBNC/iCCM commodities
D. Supportive supervision of HEWs
E. Community mobilisation, including early identiication of VSDs by WDA leaders
F. Utilisation of health posts for VSD
G. Referral of cases of newborn VSD from health post to
health centre
CBNC midline survey supervision
Supervision by team leader
At the end of each day the ield team handed their completed questionnaires – both electronic and paper-based data - to
their team leaders, who carried out a preliminary check of each
questionnaire for completeness and accuracy of the data. Any
issues identiied by the supervisors were discussed with the relevant enumerator(s) and, if required, a data-correction sheet
was completed. All issues were expected to be resolved before
leaving the health post. At the health post (cluster), the team
leader randomly re-interviewed mothers after their exit interview
to verify the key information recorded.
Supervision by Field Coordinator and Quality Assurance supervisor
The 12 survey teams were divided and overseen by the Field
Coordinator and Quality Assurance supervisor. Each directly
supervised six teams, but provided their speciic consultations to all 12 teams as needed. Furthermore, the Field Coordinator and
Quality Assurance supervisor communicated on a daily basis to
discuss both logistical and technical aspects of the survey. The
14two also communicated daily with the IDEAS Country Coordinator
who in turn provided progress reports including any technical
and operational challenges faced during the course of the survey
to the IDEAS Scientiic Coordinator.
The supervision for the CBNC midline was undertaken in two
ways: 1) through ield level supervisory visits, and 2) through telephone communication conducted on a daily basis with all
team members throughout the survey period.
A. Field level supervisory visits - ield level supervision for the CBNC midline survey was conducted immediately after
the teams were deployed to the ield. The supervision was conducted by the Field Coordinator and Quality Assurance
supervisor who visited seven out of the 12 survey teams. The
supervision covered the following aspects:
• Supported the ield teams in clarifying concepts learned in the training
• Conducted spot-checks of the ield teams at random times and without warning
• Provided refresher training
• Observed the teams’ adherence to the CBNC midline
survey protocol
• Reviewed PDA questionnaires and paper
questionnaires for consistency and completeness, and
• Provided feedback on the overall execution of the
team’s responsibilities
B. Daily supervisory calls – the Field Coordinator and Quality
Assurance supervisor had daily calls with the six teams
that they each oversaw. The supervisory call covered the
following aspects:
• Ensuring random selection of PHCUs and health posts
• Clarifying questions on the questionnaires or modules
• Tracking the number of sick children observed and
re-examined at each health post
• Strategising on efective methods for mobilisation if any mobilisation challenges arose
• Addressing any PDA related technical issues
in consultation with the JaRco PDA
programmer/data manager
• Ensuring that survey teams were utilising the data error
capture sheets for PDA related problems
Data management
Electronic data entry was conducted by the data collectors in the
ield using PDAs. The PDAs were password protected and data were stored on the PDA only during periods of data collection. At
the end of each day, data-collectors reviewed the survey data on
the tablet and then the data were transferred to the team leader.
Once reviewed, the team leader saved the data on his/her
laptop in an encrypted folder. Once data collection for a health
post was completed, the team leader uploaded the PDA data to
a secure JaRco server. Data that were uploaded by team leaders
were reviewed by JaRco’s data management team during the
course of the survey. The data management team was oriented
on monitoring consistency and accuracy checks, and provided
feedback to each team leader on a constant basis.
The HEW consultation forms, clinical vignettes and injection
assessment re-examination forms (observation-based data)
were recorded in paper format and transported to Addis
Ababa, where they were entered into CSPro survey software
at JaRco’s oices. Each questionnaire was entered into the software twice, each time by a diferent member of the data entry team. The two electronic versions of each questionnaire
were compared and reconciled by a JaRco data manager. Range
and consistency checks were carried out on the data, and values
which appear to be out-of-range or inconsistent were raised with
the appropriate survey supervisor for checking where possible.
Paper questionnaires will be stored securely at the JaRco oices for a period of three years. Electronic data at JaRco are stored
on a central secure server; backups are kept on an external hard
drive kept in a secure ire-proof cabinet. Backups are also stored on a secure server at the London School of Hygiene & Tropical
15 Medicine (LSHTM). Overall, JaRco was responsible for data
collection and management, while systematic data archiving was
the direct responsibility of LSHTM.
Analysis
The midline survey analysis focused mainly on the quality of
care delivered through CBNC. Primarily, the midline evaluation
focused on the estimation of rates of correct diagnoses and
treatment of severely sick young infants by HEWs based on an
adherence to standardised CBNC care and treatment algorithms.
The midline evaluation report presents comparative analysis
between CBNC early and late implementing areas. The CBNC
programme started in March of 2014 for early implementers,
as part of Phase I implementation, giving them on average 19
months of programme implementation at the time the midline
survey was conducted. Late implementers are areas where
CBNC was rolled out as Phase II. CBNC implementation for late
implementers started a few months (average of three months)
prior to the midline survey, indicating that HEWs had a shorter
period of time to put their training into practice. The midline
survey thus evaluates CBNC programme maturity by comparing
areas where CBNC had been fully implemented for a year or
more (early implementers) to areas where the programme had
just started prior to the survey (late implementers).
Analysis involving calculations of means for continuous variables
and categorical variables are presented as percentages. The
primary statistical analysis will be carried out at the health
post level. The point estimates for each of the indicators were
calculated and compared between early and late implementing
study areas. The focus was to describe the quality of CBNC
implementation processes at the service delivery level and
recommend means of improvement.
Signiicant diferences (p value <0.05) between early and late implementing areas should be interpreted with caution since
the sample size calculations for this survey aimed to detect a
minimum 15 percentage points change in correct classiication of young infant health status. This study was not powered to
identify a diference between zones or by implementing partners: any such analysis would be misleading, and caution is therefore
needed in interpreting its indings.
ETHICAL CONSIDERATION
Risks / beneits to subjects
Risks to study participants for involvement in the CBNC midline
evaluation were low. Participants were also informed of their
right to refuse answering any questions with which they were
uncomfortable. Respondents did not gain any direct beneits by participating in the evaluation study. However, information
obtained will be used to improve health service delivery in the
community, as well as at health facilities. With respect to HEW
assessment of sick young infants, the data collection team
facilitated a referral to the nearest health centre of any infant
observed to have a life-threatening illness.
Costs and compensation
Respondents did not receive monetary compensation and they
did not incur any out-of-pocket costs.
Conidentiality assurances
Conidentiality of every respondent was guaranteed. Unique identiiers were constructed for the questionnaires and no identiiers will be released. All questionnaires have been stored under lock and key, with access restricted to selected study
investigators. Data collection and entry was conducted by JaRco
Consulting with technical assistance from IDEAS. All data are
stored on password-protected computers with access only to the
investigators. The data sets collected through the evaluation will
be made available for public access as soon as possible.
16Conlict of interest
There are no gains from taking part in this study other than the
normal scholarly gains.
Ethical clearance
The investigators obtained a letter of approval from the
Institutional Review Boards of the London School of Hygiene &
Tropical Medicine and the Ethiopian Science and Technology
Ministry. Prior to the data collection, formal permission was
acquired from the Oromia, Amhara, Tigray and SNNP regional
health bureaus.
DISSEMINATION PLAN
The CBNC midline evaluation will be promoted through the
communication channels available to all components of the IDEAS
project. These include: the IDEAS website at http://ideas.lshtm.
ac.uk/; Research Online (an open access, searchable repository
of LSHTM-authored research outputs), peer-reviewed journal
articles, quarterly newsletters, IDEAS’ twitter account, web and
face-to-face seminars, learning workshops, LSHTM institutional
publications and professionally designed and produced research
reports and policy briefs. All communication activities are
supported by the IDEAS Communications Oicer.
In-country communications will be the joint responsibility of
the IDEAS Communications Oicer and the Ethiopia Country Coordinator.
The Ethiopia Country Coordinator, Dr Della Berhanu, leads the
Ethiopia-based CBNC team in developing and maintaining regular
communication with key stakeholders for the CBNC evaluation,
in between the production of key outputs from the evaluation.
The London-based CBNC leadership team will be present for key
stakeholder meetings and dissemination events. Records will be
kept by the IDEAS Communications Oicer of all dissemination activities and outputs relating to the CBNC evaluation.
National: Dissemination of results at national level will irst be to the Federal Ministry of Health, the Technical Working Group
(TWG) for the CBNC evaluation, and the Ministry of Science and
Technology. Wider dissemination of CBNC evaluation results will
only take place once approval has been granted by them.
The CBNC implementing organisations are represented on the
TWG, but discussions with each implementer regarding the
evaluation study indings will also be held on request. The CBNC evaluation team is open to suggestions by the TWG of relevant
fora in which to present the study indings, in collaboration with TWG members, including Federal Government, where
appropriate.
Ethiopian regional: Regional dissemination events will take
place in the regional health bureaus for Amhara, Oromia, SNNP
and Tigray. These will be planned and delivered in partnership
with each region’s government. Key stakeholders representing
community-level, primary and secondary health care, government
and implementing partners (non-governmental organisations
-NGOs) will be invited.
International: Research reports and policy briefs from the
CBNC evaluation will be made available globally via the IDEAS
website and the London School of Hygiene & Tropical Medicine’s
Research Online portal. Academic and policy-relevant conference
papers and peer reviewed journal articles will also be produced,
in collaboration with members of the TWG, where there is
mutual interest to work together.
5. Farrington, C. P. and Manning, G. (1990). “Test statistics and sample size formulae for comparative binomial trials with null
hypothesis of non-zero risk diference or non-unity relative risk.” Statistics in Medicine, Vol. 9, pages 1447-1454. 6. Keble command post: kebele level administrative group responsible for oversight of WDA leaders.
17
In the facility readiness for CBNC services section,
we will provide a description of facility structure,
equipment, medicine, background on health workers
and staf numbers. Service utilisation, linkages and supportive supervision are described under the function
of health facilities section.
FACILITY READINESS FOR CBNC SERVICES
Facility infrastructure
This study conducted an observation of infrastructure at the
health centre (Table 5A) and health post (Table 5B). Almost
all health centres had a patient toilet and steriliser. Sixty-
nine percent had water on the day of the survey, which was
higher among facilities in early implementing areas (81%
vs 51%, p<0.001). Electricity and cell phone signal was
available in over 70% of health centres. Only 22% reported
having a facility phone. Staf member phone was the main means of communicating with other health facilities (84%).
Among health posts, 66% had water on the day of the
survey. In contrast to health centres, a smaller proportion
of health posts in early implementing areas had water on
the day of the survey (56% vs 80%, p<0.001). A patient toilet
was available in 78% of health posts, with the proportion
being higher among early implementing areas (83% vs
70%, p=0.02). The availability of a cell phone signal was
also higher among early implementing areas (71% vs 56%,
p=0.01). Only 10% of health posts had electricity on the day
of the survey. Similar to health centres, the main means
of communication with other facilities was staf phone. In-person communication was reported in about half of the
health posts visited.
3. HEALTH SYSTEM READINESS FOR QUALITY CBNC SERVICES
This chapter provides information on the
health system readiness to provide quality
of CBNC services. The study included 30
woredas (18 early and 12 late implementing
area). A total of 117 PHCUs (70 early and
477 late implementing area) and 240 health
posts (140 early and 100 late implementing
area) were visited. Interviews were
conducted with staf members at the 117
PHCUs as well as interviews with 240 HEWs
and 240 WDA leaders
CHAPTER SECTIONS
1. Facility readiness for CBNC services
2. Function of health facilities
18Table 5A. Health centre: observation of infrastructure
Table 5B. Health post: observation of infrastructure
EARLY
IMPLEMENTERS
LATE
IMPLEMENTERS
TOTAL
N=70 N=47 N=117
% % %
Facility description
Water available on the day of survey* 81 51 69
Patient toilet 100 98 99
Electricity available on the day of survey 78 64 72
Functional steriliser 100 93 97
Functional fridge 100 100 100
Cell phone signal available on day of survey 76 68 73
Means of communication with other health facilities
Facility phone 19 28 22
Staf phone* 91 72 84
Community member phone* 13 2 9
*p<0.05 for test of diference between early and late implementers
EARLY
IMPLEMENTERS
LATE
IMPLEMENTERS
TOTAL
n=140 n=100 N=240
% % %
Facility description
Water available on the day of survey* 56 80 66
Patient toilet* 83 70 78
Electricity available on the day of survey* 6 15 10
Functional steriliser 15 23 18
Functional fridge 4 10 7
Cell phone signal available on day of survey* 71 56 65
Means of communication with other health facilities
Facility phone* 18 2 11
Staf phone 59 69 63
Community member phone* 1 7 4
In-person communication * 38 65 49
*p value<0.05 for test of diference between early and late implementers
19
Figure 4. Health centre and health post: source of drinking water
0%
20%
40%
60%
80%
100%
Late implementers (n=47)Early implementers (n=70)
Health post: unsafe drinking waterHealth centre: unsafe drinking water
% o
f fac
ilitie
s
27 26 2727
Table 6A. Health centre: observed availability of newborn health related equipment and supplies
EARLY
IMPLEMENTERS
LATE
IMPLEMENTERS
TOTAL
N=70 N=47 N=117
% % %
Equipment
Clinical Thermometer, digital 80 70 76
Clock 99 96 97
Infant scale 99 98 98
Tape measure 89 85 87
Stethoscope 99 98 98
Ambu bag 97 96 97
Suction bulb 91 92 92
Warmer for newborn care 31 38 34
Nasogastric tube 21 26 23
Supplies
Clean gloves 93 94 93
Syringes with needles for gentamycin 94 96 95
Sharps container 97 98 97
Soap 54 57 56
Hand sanitiser (alcohol) 49 47 48
Surgical gloves 96 98 97
Water for injection 80 92 85
IV cannula 59 72 64
IV luid 5% DW 61 70 65
IV luid 5% NS 87 85 86
20Figure 4 shows the source of drinking water for health centres
and health posts. A little over a quarter of health posts and health
centres in both early and late implementing areas used unsafe
drinking water. The deinition of safe and unsafe drinking water is shown in Box 1.
Table 6A shows the observed availability of newborn health
related equipment and supplies at health centres. Over 90%
had a clock, infant scale, stethoscope, suction bulb and ambu
bag. Facilities were also well supplied with respect to clean
gloves (93%), surgical gloves (97%), gentamycin syringes (95%)
and sharps container (97%). Thirty-four percent had a warmer
for newborns. Hand sanitiser (alcohol) and soap were observed
in only 48% and 56% of health centres, respectively. Overall,
there was no evidence of a diference between early and late implementing areas with respect to equipment and supplies at
the health centre level.
Table 6B shows the observed availability of newborn health
related equipment and supplies at health posts. Distribution of
equipment and supplies was more or less similar between early
and late implementing areas. Over 90% had a digital clinical
thermometer, weighing sling and mid-upper arm circumference
(MUAC) tape measure. Clock and tape measure were observed
Table 6B. Health post: observed availability of newborn health related equipment and supplies
EARLY
IMPLEMENTERS
LATE
IMPLEMENTERS
TOTAL
N=140 N=100 N=240
% % %
Equipment
Clinical thermometer, digital 97 99 98
Clock 63 55 60
Infant scale* 96 79 89
Weighing sling 94 95 94
Tape measure 56 55 55
Stethoscope 75 67 72
MUAC tape measure* 99 94 97
Supplies
Clean gloves 84 75 80
Syringes with needles for gentamycin 84 88 86
Sharps container 84 87 85
Soap 30 34 32
Hand sanitizer (alcohol) 19 27 23
*p<0.05 for test of diference between early and late implementers
21 available compared with late implementing areas (77% vs 93%,
p=0.03). Overall, 84% of health posts had both drugs, 13% had
one and 3% had neither.
The survey also assessed the availability of drugs for treatment
of infants 0-2 months old at health posts (Table 7C). As per the
treatment protocol, infants between the ages of 0-2 months with
mild dehydration are treated with zinc for ten days. Newborns
with mild dehydration, severe dehydration, severe persistent
diarrhoea or dysentery require oral rehydration solution (ORS).
Two-thirds of health posts had ORS on the day of the survey while
only 26% had zinc. Approximately a quarter of health posts had
expired ORS and half had expired zinc. Both zinc and ORS were
available in around a quarter of health posts, with approximately
31% having neither drug (Figure 6).
Human resources: staf proile
Health centres on average had 15 staf members, eight nurses, two health oicers, two midwives, one pharmacist and two laboratory technicians (Figure 7). Early and late implementing
areas had a similar distribution of staf members except for nurses, for which on average, early implementing areas had a
higher number (9 vs 7, p<0.01).
By design a health centre and, on average, ive satellite health posts comprise a PHCU. Each health post in turn is stafed by two HEWs. Figure 8 shows the distribution of health posts and HEWs
by implementation area. Early implementing area PHCUs had a
fewer number of health posts (4 vs 6, p=0.001). Furthermore,
on average early implementing areas had more than twice as
many HEWs as health posts, indicating that they are well stafed. In contrast, late implementing areas on average had fewer than
two HEWs per health post, suggesting a relative shortage of staf.
in 60% and 55% of health posts, respectively. Eighty-nine percent
had infant scales, with the proportion being higher among early
implementers (96% vs 79%, p<0.001). With respect to supplies,
over 80% of health posts had clean gloves, gentamycin syringes
and a sharps container. Similar to health centres, less than a
third of health posts had hand sanitiser (alcohol) and soap.
This survey also observed the availability of newborn health
related drugs at facilities. Almost all health centres (Table 7A)
had some form of gentamycin (90%) or amoxicillin (93%),
while 83% had both. A higher proportion of health centres in
early implementing areas were observed to have gentamycin
20mg/2ml (49% vs 11%, p<0.001). Sixty-eight percent of health
centres had ampicillin. Over 75% of health centres had Vitamin
A, Tetracycline (TTC) eye ointment, paracetamol, BCG and polio
vaccine. Vitamin K and chlorohexidine was available in 34% and
38% of health centres, respectively.
The availability of drugs for treatment of very severe disease at
health posts is shown in Table 7B. Following the CBNC protocol,
a neonate with severe bacterial infection should be provided
with a pre-referral dose of gentamycin injection (20mg/2ml)
and amoxicillin tablet (half of a 250 mg or 125 mg dispersible
tablet) or syrup (125 mg/5ml). If referral is not possible, then the
neonate is given gentamycin injections by a HEW for seven days.
The care provider is then informed to give the baby amoxicillin at
home for seven days. A neonate with a local bacterial infection is
treated with amoxicillin for ive days.
Amoxicillin (250 mg dispersible tablet, 125 mg dispersible tablet
and/or 125 mg/5ml syrup) was available in 97% of all health
posts. Among the 3% of health posts that had no amoxicillin the
average duration of non-availability was 69 days. The detailed
availability of amoxicillin in the diferent forms is also shown in table 7B. Gentamycin 20mg/2ml was available in 91% of
health posts. Where stock-out was reported the average length
of non-availability was 94 days. Figure 5 shows the availability
of gentamycin and amoxicillin drugs by implementation areas. A
smaller proportion of early implementing areas had both drugs
22
Figure 6. Health post: observed availability for neonatal diarrhoea related drugs (ORS and zinc)
0%
20%
40%
60%
80%
100%
Late implementers (n=100)Early implementers (n=140)
None availableOne drug availableBoth drugs available
% o
f fac
ilitie
s
25 23
4942 2833
Figure 5. Health posts: observed availability of drugs! for VSD
! Both gentamycin (20mg/2ml) and amoxicillin (250 mg dispersible tablets, 125 mg dispersible tablets and/or
125 mg/5ml syrup)
* p-value <0.05 for test of diference between early and late implementers
0%
20%
40%
60%
80%
100%
Late implementers (n=100)Early implementers (n=140)
None availableOne drug availableBoth drugs available
% o
f fac
ilitie
s
77
93
5
20
23
Figure 7. Health centre: available staf
*p value <0.05 for test of diference between early and late implementers
02468
1012141618
Late implementers (n=47)Early implementers (n=70)
Lab
technicians
PharmacistsUrban HEWsMidwivesHealth oicersNurses*Total
Mea
n no.
of sta
f
1614
7
9
122 2 2 2
1 12 1
23 Table 7A. Health centre: observed availability of MNH related drugs
DRUGS EARLY
IMPLEMENTERS
LATE
IMPLEMENTERS
TOTAL
N=70 N=47 N=117
% % %
Management of very severe disease
Amoxicillin dispersible tablet 250 mg 53 55 54
Amoxicillin dispersible tablet 125 mg 34 17 27
Amoxicillin suspension 125mg/5ml 79 79 79
Any Amoxicillin 93 94 93
Gentamycin injectable 20mg/2ml* 49 11 33
Gentamycin injectable 80mg/2ml 86 85 86
Any gentamycin 91 87 90
Any gentamycin and any amoxicillin 84 81 83
Ampicillin 500 mg 64 74 68
Newborn care and vaccinations
Iron 83 81 82
Folate* 79 22 56
Vitamin K 1mg 30 40 34
Vitamin A 200,000 IU* 24 0 15
Vitamin A 100,000 IU 76 79 77
TTC eye ointment 80 92 85
Chlorohexidine* 51 17 38
Ampicillin powder 64 75 68
Paracetamol 87 75 82
BCG 86 75 81
Polio vaccine 89 83 86
*p<0.05 for test of diference between early and late implementers
Figure 8. PHCU: average number of health posts and HEWs
0
2
4
6
8
10
12
Late implementers (n=47)Early implementers (n=70)
HEWsHealth posts*
Mea
n no
.
4
6
109
*p value <0.05 for test of diference between early and late implementers
24Table 7B. Health post: observed availability of newborn drugs for treatment of very severe disease
Table 7C. Health post: observed availability of newborn drugs for treatment of dehydration
*p<0.05 for test of diference between early and late implementers
EARLY
IMPLEMENTERS
LATE
IMPLEMENTERS
TOTAL
N=140 N=100 N=240
% % %
Any Amoxicillin 96 98 97
Amoxicillin dispersible tablet 250 mg* 55 19 40
Amoxicillin dispersible tablet 125 mg* 41 82 58
Amoxicillin suspension 125 mg/5 ml 34 30 33
Gentamycin injectable 20mg/2ml* 87 96 91
a Among the drug stock-out/expiry
EARLY
IMPLEMENTERS
LATE
IMPLEMENTERS
TOTAL
N=140 N=100 N=240
% % %
ORS
Available 66 69 67
Not available 9 10 10
Expired 25 21 23
Duration of non-availability (mean days)a 100 105 102
Zinc
Available 26 26 26
Not available 28 16 23
Expired 46 58 51
Duration of non-availability (mean days)a 95 104 99
25 Health post operations: availability of CBNC services over the course
of a week
The number of HEWs per health post is shown in Table 8. HEWs
reported that about a quarter of health posts only had one
HEW, 65% had two and 11% had three or more. Approximately
15% of health posts were open less than ive days of week, with 85% operating for ive working days a week or more. Figure 9 shows the health post operational days by
implementation area. HEWs were also asked where
community members seek care during weekends or holidays. A
little over a half stated that the community sought care with them,
with the proportion being smaller among early implementing
area HEWs (41% vs 67%, p<0.001).
The availability of HEWs in close proximity of the community is
essential to ensure that a newborn with VSD receives gentamycin
injections for seven days. In this study, only 46% of HEWs were
provided with oicial housing in the kebele where they work.
FUNCTION OF PHCUS FOR CBNC RELATED SERVICES
This section presents the level of linkages, service utilisation and
supportive supervision within PHCU.
CBNC related linkages
This study explored the linkages at the diferent levels of the PHCU. Linkages between health posts, WDA leaders
and the community were explored speciically looking at meetings, pregnant women’s conference and other community
level activities.
Meetings
Seventy-three percent of WDA leaders reported more than one
meeting with HEWs in the last three months, while 14% had had
no meeting. WDA leaders were asked if they were satisied with their HEW interactions and 91% reported that they were satisied.
Pregnant women’s conference
Midwives from the health centres jointly with HEWs and WDA
leaders are expected to conduct a pregnant women’s conference
at least once a month, most commonly at the kebele level. Almost
all health centres (98%), a majority of health posts (87%) and
WDA leaders (82%) reported the conduct of a pregnant women’s
conference in the last three months. Compared with HEWs (66%)
and WDA leaders (61%), a higher proportion of health centres
(79%) reported organising a conference once a month. This can
be explained by the fact that health centres are likely reporting
on all the conferences organised in the multiple kebeles within
their PHCU.
There were notable diferences between early and late implementing areas with respect to the organisation of
conferences by HEWs and WDA leaders. A smaller proportion
of early implementing area HEWs reported having monthly
Box 1: Source of drinking water
Unsafe drinking water
Boreholes
Rainwater collection
Surface water
Open dug wells
Unprotected springs
Tanker
Safe drinking water
Piped connection into health post
Piped connection into yard
Public standpipes
Protected dug wells
Protected springs
Vendor provided water
Bottled water
26Table 8. Health post: characteristics a
a Reported by HEWs leader
*p<0.05 for test of diference between early and late implementers
EARLY
IMPLEMENTERS
LATE
IMPLEMENTERS
TOTAL
N=140 (%) N=100 (%) N=240 (%)
Number of HEWs at health post*
One 18 33 24
Two 66 64 65
Three or more 16 5 11
Facility operational days/week (mean) 5 5 5
Community place of care seeking during weekend/holiday reported by HEWs
Health centre 84 87 85
Health posts/HEW* 41 67 52
Pharmacy 6 9 7
Oicial housing provided to HEWs by kebele 50 41 46
Figure 9. Health post: number of operational days in a week
0
20
40
60
80
100
Late implementers (n=100)Early implementers (n=140)
Open 5 days or more a weekOpen less than 5 days a week
% o
f hea
lth p
osts
12 18
8288
Health posts’ number of operational days
27 conferences (56% vs 81%, p<0.001). In contrast, a greater
proportion of early implementing area WDA leaders reported
having monthly conferences compared with late implementing
area leaders (70% vs 48%, p<0.001). It is expected that a higher
proportion of HEWs would report organising a conference, as
the WDA leaders interviewed might not have assisted in the
organisation of a conference. However, a higher proportion
of WDA leaders than HEWs reporting organising a conference,
as seen in early implementing areas, indicates that the task of
organising conferences might be up taken by WDA leaders, but
more research is needed to understand the phenomena further.
With respect to attendance, 59% of HEWs reported that all the
pregnant women in their catchment population were present
at the most recent pregnant women’s conference. This number
increased to 85% among WDA leaders.
Other linkages
WDA leaders reported that they undertake the following activities
with HEWs: plan together (68%), organise pregnant women’s
conference (80%), provide household visits (86%), and conduct
health campaigns (81%). Of these activities, conducting health
campaigns was diferent between early and late implementing areas (88% vs 72%, p<0.01).
WDA leaders were also asked about their linkages with key
igures in the community to discuss MNH related issues in the last six months (Figure 10). Forty-seven percent reported that
they had met with religious leaders, 53% with edir8 groups, 59%
with women’s saving groups, 49% with the kebele command post
and 26% with traditional birth attendants. Of these, a greater
proportion of early implementing areas reported linking with
religious leaders (52% vs 39%, p=0.04) and command post (65%
vs 27%, p<0.001).
Supervision
In this section the level of supervision that is provided to health
posts is assessed. There are four types of supervision that were
explored (Figure 11):
1. Integrated supportive supervision
2. CBNC/iCCM programme based supervision
3. Performance Review and Clinical Mentoring (PRCM)
meetings, and
4. CBNC post-training follow-up visit
Integrated supportive supervision covers the diferent packages of the Health Extension Program and takes place twice a month.
HEWs are also supposed to receive a programme-focused
supervision for CBNC and iCCM from health centre staf, woreda health oice and programme implementing partners, ideally once per month. PRCM meetings are group meetings held twice
a year for HEWs trained in CBNC/iCCM and supervisors trained
in IMNCI/CBNC. The meetings aim to improve the technical
skills and knowledge of HEWs and their supervisors. A PRCM is
a biannual meeting, planned to take place six months after the
initial CBNC training. HEWs are also supposed to receive a post-
training follow-up visit within six weeks of their CBNC training.
Figure 12A shows the reported level and type of supervision by
health centres to health posts. Ninety-eight percent of health
centres reported that they had visited a health post in their
catchment population in the last six months for integrated
supportive supervision and 75% had provided a visit in the last
month. The level of integrated supportive supervision in the
last six and one months were similar between early and late
implementing areas.
A higher proportion of early implementing areas reported having
organised a PRCM meeting (87% vs 60%, p=0.001) in the last six
months. Given that a PRCM meeting is planned to take place six
months after the initial CBNC training, late implementers might
not have been eligible for such a meeting since on average CBNC
training had taken place approximately three months prior to
28
*p<0.05 for test of diference between early and late implementers
Figure 11: Supervision: recommended types and frequency of supervision provided to HEWs
1 2 3 4 5 6
BIWEEKLY INTEGRATED SUPPORTIVE SUPPERVISION
MONTHLY CBNC/ICCM PROGRAMME SUPERVISION
SIX WEEKS POST-CBNC TRAINING FOLLOW-UP VISIT
BIANNUAL PRCM MEETING
MONTHS
Figure 10. Linkage between WDA and community stakeholders: meeting with key community igures to discuss MNH in the last six months
0
20
40
60
80
100
Late implementers (n=100)Early implementers (n=140)
TBAsCommand
post*
Women's savings
group
EdirReligious leaders*
% o
f WDA
lead
ers
52
3951 54 59 58
65
27 2429
29 Figure 12A. Supervision provided: reported by health centres for any of their respective health posts
Figure 12B. Supervision received: reported by health posts
a Performance Review and Clinical Mentoring
*p<0.05 for test of diference between early and late implementers
a Performance Review and Clinical Mentoring
*p<0.05 for test of diference between early and late implementers
0
20
40
60
80
100
Late implementers (n=47)Early implementers (n=70)
Last 1 monthLast 6 monthsLast 6 months
% o
f WDA
lead
ers
87
60
99 98
7772
Integrated supportive supervision
provided to any health post
Focused supervision
(PRCM)a meeting
0
20
40
60
80
100
Late implementers (n=100)Early implementers (n=140)
Last 1 monthLast 6 monthLast 6 months*
% o
f Hea
lth p
osts
82
45
86 82
47 50
Integrated supportive supervision
provided to any health post
Focused supervision
(PRCM)a meeting
30Table 9A. Supportive supervision: visits to health posts during last six months.
Table 9B. Supervision: CBNC post-training follow-up visits to health posts.
a Among the 202 HEWs (120 in early and 82 in late implementing areas) who received an integrated supportive
supervision in the last six months b Joint visit: Woreda health oice, health centre and/or implementing partner (NGO) c Among the 140 HEWs (97 in early and 43 in late implementing areas) who received an CBNC/iCCM supervision
in the last six months
*p<0.05 for test of diference between early and late implementers
AMONG THOSE RECEIVING SUPERVISION
IN LAST SIX MONTHS
EARLY
IMPLEMENTERS
LATE
IMPLEMENTERS
TOTAL
% % %
A. Integrated supportive supervisiona
Woreda health oice 73 67 70
Health Centre* 80 63 73
Implementing partner (NGO) 62 48 56
Provider of most recent visit*
Woreda health oice 13 24 18
Health centre 66 34 53
Implementing partner (NGO) 10 18 13
Joint visitb 11 23 15
B. CBNC/iCCM supervisionc
Woreda health oice 32 40 34
Health centre 52 56 53
Implementing partner (NGO)* 73 49 66
*p<0.05 for test of diference between early and late implementers
EARLY
IMPLEMENTERS
LATE
IMPLEMENTERS
TOTAL
N=140 N=100 N=240
% % %
Follow-up visit within 6 weeks of training* 51 28 41
Among those receiving supervision
Provider of post-training supervision
Zone 6 7 6
Woreda* 14 68 29
Health centre 39 43 40
Implementing partner 70 57 67
31 the date of the midline survey. Overall, 76% of health centres
reported organising a PRCM meeting in the last six months.
Figure 12B shows the type and frequency of supervision received
by HEWs. Integrated supportive supervision visits in the last six
months were reported by 84% of HEWs and only 48% reported a
visit in the last month. This indicates that over half of the health
posts in this study did not get supportive supervision visits in the
last month, which among other things, are intended to reinforce
HEWs’ service provision skills.
Overall, 67% of health posts reported attending a PRCM meeting
in the last six months. As mentioned earlier, PRCM meetings
are planned to take place six months after CBNC training which
explains the higher proportion of HEWs in early implementing
areas who reported a PRCM meeting attendance (82% vs 45%,
p<0.001). Fifty-eight percent of HEWs (69% in early and 43% in
late implementing area, p<0.001) reported receiving an CBNC/
iCCM programme speciic supervision in the last six months.
Table 9A shows who provided supervision to HEWs in the last
six months. Supervision for CBNC/iCCM was mainly provided
by the implementing partners (66%) and health centres (53%).
Some of these visits are likely to have taken place jointly between
a government health worker and an implementing partner,
although this was not assessed for CBNC/iCCM programme
speciic supervision.
Over 70% reported that they had received an integrated
supportive supervision visit in the last six months from health
centre and woreda health oice staf, with over half reporting that they had also received a visit from the programme-implementing
partner. With respect to the most recent supervisory visit, 18%
reported a visit from the woreda health oice. Fifty-three percent said that the most recent visit was from health centre staf, 13% from implementing partners and another 15 reported a joint visit
from all three. A joint visit by health centres and implementing
partners together was reported by 8% of health posts.
As mentioned previously, HEWs are expected to receive a post-
training follow-up supervision visit within the irst six weeks of training. As shown in Table 9B, 41% of HEWs reported receiving
a such a visit, with the proportion being greater among early
implementing areas (51% vs 28%, p <0.001). For some HEWs it
might not be clear that a visit falls under the category of a regular
supportive supervisory visit or a post-training follow-up visit,
which might result in the under reporting of post-training follow-
up visits. Two-thirds of health posts reported that implementing
partners were present at the post-training visit and 40% reported
that health centre staf members were present. Woreda staf presence was also reported by 29% of HEWs, with the proportion being smaller in early implementing areas (14% vs
68%, p<0.001).
Health centre staf that provided supportive supervision in the last six months (N=115) were provided with a list of CBNC
“OVER HALF OF
THE HEALTH POSTS
STUDIED DID NOT
GET SUPPORTIVE
SUPERVISION
VISITS IN THE
LAST MONTH.”
32Table 10A. Supportive supervision provided by health centres (prompted): content of supervision in
the last 6 months
*p<0.05 for test of diference between early and late implementers
CONTENT OF SUPERVISION
AMONG THOSE PROVIDING SUPPORTIVE
SUPERVISION
EARLY
IMPLEMENTERS
LATE
IMPLEMENTERS
TOTAL
N=69 N=46 N=115
% % %
A. Discussion
Maternal
Early identiication of pregnancy 100 98 99
Focused ANC 97 96 97
Institutional delivery 99 96 97
Newborn
Immediate newborn care* 87 59 76
Asphyxia management* 77 35 60
Hypothermia prevention and management* 84 30 62
Pre-term and low birth weight* 80 26 58
VSD management* 94 57 79
Staf
HEW activity with WDA 96 91 94
Written feedback on HEWs’ work 86 85 85
B. Observation
HEW interaction with mother and newborn* 64 39 54
Record keeping* 97 87 93
Register* 93 74 85
Availability of supplies 88 74 83
C. Provision
Supplies* 91 65 81
33 programmatic themes and were asked to pick topics they
covered during their supervisory visit (Table 10A). With respect
to maternal care, almost all health centres reported discussing
pregnancy identiication, focused ANC, and institutional delivery. A large proportion of health centres also addressed HEWs’ activity
with WDA leaders (94%) and provided written feedback on
HEWs’ work (85%). However, discussion around newborn care
was not as high. For example, VSD management and immediate
newborn care were covered by 76% and 79% of health centres,
respectively. Coverage of these and other newborn care topics
were higher in early implementing areas (VSD: 94% vs 57%,
p<0.001; immediate newborn care: 87% vs 59%, p<0.01).
Over 80% reported observing HEWs’ record keeping, registers
and availability of supplies. However, observation of HEWs
interaction with mothers and newborns was done by only 54%
of health centres. Over 80% reported that supervisory visits were
also used to provide health posts with supplies.
HEWs who received supportive supervision in the last six months
(N=202) were also provided with a list of CBNC programmatic
areas and asked to choose themes that were covered during the
supervisory visit (Table 10B). The supervision that was provided,
as reported by health centres, and the supervision that was
received, as reported by health posts, followed the same trend.
However, the health centre reports overestimated reports from
health posts, because they reported on supervision to any health
post in their catchment area. In contrast, health post values
relect speciic activities undertaken in that location and therefore better relect the level of supervision provided by health centres to a speciic health post. Overall, there were diferences between early and late implementing areas, however the diferences were minor.
With respect to maternal care, the majority of HEWs reported
that early identiication of pregnant women and institutional delivery were discussed during visits in the last six months (90%
and 78%, respectively). In contrast, discussion on focused ANC
was reported by 44% of HEWs.
Supervision on newborn care was consistently low, with less
than 50% of HEWs reporting discussion on immediate newborn
care and VSD management. Observation of HEW interaction with
mother and newborn was reported by only 29% of HEWs.
Discussion on HEWs’ activity with WDA leaders during a
supervisory visit was reported by three quarters of HEWs. Written
feedback by health centre staf on HEWs’ work was veriied among 42% of HEWs, and this was higher among early implementing
areas (51% vs 29%, p<0.01). Over 70% of HEWs reported that
supervision covered observation of record keeping and registers.
A smaller proportion of early implementing areas reported that
supervision observed their record keeping (68% vs 83%, p=0.02).
A little over a third of HEWs reported that supervisory visits were
also used to provide health posts with supplies.
Health centres that had organised PRCM meetings in the last
six months (N=89) were asked to select from a list, the content
covered during the meeting (Table 11A). With respect to
maternal care, almost all reported that early identiication of pregnancy was discussed and 83% reported discussing focused
ANC. Around 70% addressed institutional delivery.
With respect to newborn care, 98% reported discussing neonatal
diarrhoea management, and around 80% reported discussing
immediate newborn care, asphyxia management, hypothermia
and preterm/low birth weight. Breastfeeding and neonatal
immunisation was discussed 75% and 70%, respectively. Only
half of the health centres reported covering VSD management.
Seventy-one percent reported that data was extracted from the
0-2 month iCCM registers and 78% provided skills mentoring
for HEWs on newborn care. Compared with late implementing
areas, there was a consistent pattern of PRCM meetings in
early implementing areas covering more content on MNH
management practices.
HEWs who had participated in a PRCM meeting the last six
months (N=161) were asked to select from a list of thematic
areas, those areas covered during the meeting (Table 11B). With
34Table 10B. Supportive supervision received by health posts (prompted): content of supervision visit in
the last 6 months
*p<0.05 for test of diference between early and late implementers
CONTENT OF SUPERVISION
AMONG THOSE RECEIVING SUPPORTIVE
SUPPERVISION (HEW)
EARLY
IMPLEMENTERS
LATE
IMPLEMENTERS
TOTAL
N=120 N=82 N=202
% % %
A. Discussion
Maternal
Early identiication of pregnancy 91 88 90
Focused ANC 43 45 44
Institutional delivery 83 72 78
Newborn
Immediate newborn care 39 40 40
Asphyxia management 24 28 26
Hypothermia prevention and management 23 27 24
Pre-term and low birth weight 32 29 31
VSD management 39 44 41
Staf
HEW activity with WDA 78 66 73
Written feedback on HEWs’ work (veriied)* 51 29 42
B. Observation
HEW interaction with mother and newborn 28 31 29
Record keeping* 68 83 74
Register 73 74 73
Availability of supplies 40 40 40
C. Provision
Supplies 42 28 36
35 Table 11A. Supportive supervision provided by health centres (prompted): content of group PRCM
meeting in the last six months
*p<0.05 for test of diference between early and late implementers
CONTENT OF PRCM MEETING
AMONG THOSE PROVIDING PRCM
EARLY
IMPLEMENTERS
LATE
IMPLEMENTERS
TOTAL
N=61 N=28 N=89
% % %
A. Discussion
Maternal
Early identiication of pregnancy 98 100 99
Focused ANC* 77 96 83
Institutional delivery* 87 29 69
Newborn
Immediate newborn care* 95 57 83
Asphyxia management * 95 64 85
Neonatal diarrhoea management * 100 93 98
Breastfeeding* 89 46 75
Neonatal immunisation* 82 43 70
Hypothermia prevention and
management*
92 54 80
Preterm and low birth weight * 90 64 82
VSD management* 61 29 51
B. Demonstration
Skills mentoring newborn care to HEWs* 98 32 78
C. Data extraction
iCCM 0-2 month register* 89 32 71
36Table 11B. Supportive supervision received by health posts (prompted): content of group PRCM
meeting in the last 6 months.
*p<0.05 for test of diference between early and late implementers
CONTENT OF PRCM MEETING
AMONG THOSE RECEIVING PRCM (HEW)
EARLY
IMPLEMENTERS
LATE
IMPLEMENTERS
TOTAL
N=131 N=30 N=161
% % %
A. Discussion
Maternal
Early identiication of pregnancy 99 100 99
Focused ANC* 88 100 90
Institutional delivery 95 93 95
Newborn
Immediate newborn care 70 60 68
Asphyxia management* 63 37 58
Neonatal diarrhoea management* 83 57 78
Breastfeeding 77 67 75
Neonatal immunisation 79 83 80
Hypothermia prevention and management* 63 33 58
Preterm and low birth weight* 70 40 65
VSD management* 79 57 75
B. Demonstration
Skills mentoring newborn care to HEWs* 92 70 88
Newborn care at home 51 53 52
C. Data extraction
iCCM 0-2 month register* 95 70 90
37 respect to maternal care, over 90% reported that the meeting
covered early identiication of pregnancy, focused ANC and institutional delivery.
With respect to newborn care, 58% reported that asphyxia
and hypothermia management were discussed, while round
two-thirds reported discussion on immediate newborn care
and preterm and low birth weight. Around 75% said that
neonatal diarrhoea, breastfeeding and VSD management were
discussed. Eighty percent said that the meeting covered neonatal
immunisation. With the exception of immunisation, discussions
on all other aspects of newborn care were higher in early
implementing area meetings. Data extraction from the 0-2 month
iCCM register was reported by 90% of HEWs. Eighty-eight percent
said that skills mentoring for newborn care were demonstrated
to HEWs. In contrast to what was reported by health centre
staf (0%), 52% of HEWs reported conducting a joint visit to demonstrate newborn care at home.
HEWs were asked about their level of satisfaction with the
supervision that they had received (Table 12). About half of HEWs
(53%) said that they were not fully satisied with their supervision. Satisfaction with supervision did not difer by implementation areas. When asked how their supervision might be improved,
the majority (69%) reported the need to increase visits. This
mirrors the results shown in Figure 12B (above) where less than
half of HEWs reported receiving supportive supervision in the
last month. In addition, 64% of HEWs reported that supervision
would be improved by more technical supervision.
Service utilisation
The maternal and child health department focal person at health
centres was asked about expected services for the PHCU and
actual service provided at the health centre (Table 13A) in the
quarter preceding the date of the midline survey (July-September
2015). On average each PHCU expected 208 pregnancies in the
previous three months and the expected number were similar
between implementation areas.
Women are encouraged to have a minimum of four ANC
consultations during their pregnancy, of which visit one (1st
trimester) and visit 4 (late 3rd trimester) are encouraged to take
place at the health centres while visit two (2nd trimester) and
visit three (early 3rd trimester) are provided by HEWs. From the
register review, it was evident that in some health centres ANC
visits were recorded based on the number of visits a pregnant
women had (where the average ANC visit one ≥ ANC visit two ≥ ANC visit Three ≥ ANC visit four), while in other health posts it depended on the timing of the visit (where the average ANC visit
one was smaller than ANC visit four). If, for example, a woman
has her irst ANC visit late in her third trimester, it is likely to be recorded as ANC visit four. This diference in practice potentially leads to misclassiication in record keeping.
Service records maintained at the health centre indicated that on
average 149 women had ANC visit one at the health centre in
the three months preceding the survey. The fact that the average
number of ANC visits for visit one (149) and four (86) are higher
than averages for visits two (58) and three (44) indicates that, as
per the guidelines, the irst and last visits are taking place at the health centre.
Although the two implementation areas were similar with respect
to expected pregnancies as well as ANC visits one and two, early
implementing areas had a higher average number of women
seeking ANC visit three (51 vs 33, p=0.04) and ANC visit four (103
vs 61, p<0.01). With respect to targets, if on average a PHCU
expects 208 pregnant women and on average 149 women had
at least one ANC visit, it indicates that 28% of expected pregnant
women did not receive any ANC visits.
On average PHCUs expected to have 204 facility births in the
three months preceding the survey and had recorded 133mean
deliveries. Early implementing areas had a higher mean for
deliveries (156 vs 98, p<0.0001). On average health centres had
one stillbirth in the previous three months.
38
Table 13A. Health centre register review: services provided for pregnant women in the last
three months
EARLY
IMPLEMENTERS
LATE
IMPLEMENTERS
TOTAL
N=70 N=47 N=117
MEAN MEAN MEAN
Expected services
Pregnancies 206 212 208
Facility births 203 206 204
Provided services
ANC
Visit one (1st trimester) 152 146 149
Visit two (2nd trimester) a 63 51 58
Visit three (3rd trimester)* a 51 33 44
Visit four (3rd trimester) * 103 61 86
Number of total facility deliveries* 156 98 133
Number of live births 156 97 132
Number of still births* <1 1 1
a N=113: 4 Health centres that did not record ANC not included (1% of early 6% of late implementers)
*p<0.05 for test of diference between early and late implementers
Table 12. Supportive supervision received by health posts: HEW satisfaction a
EARLY
IMPLEMENTERS
LATE
IMPLEMENTERS
TOTAL
N=124 N=77 N=201
% % %
Satisfaction with supportive supervision 57 47 53
Suggestion to improve supervision
Increase visits 68 71 69
More technical supervision 61 68 64
a Among HEWs receiving supervision in the last 6 months
39 HEWs were also asked about expected services and actual
services provided at the health post in the quarter preceding
the date of the survey (Table 13B). On average each health post
expected 44 pregnancies in the previous three months. According
to service records maintained at the health post, on average 22
women were provided with ANC visit one, 12 with visit two, 19
with visit three and 14 with visit four. Early implementing areas
had a higher number of mean expected pregnancies (47 vs 39,
p=0.01), which could have resulted in the higher mean number
of ANC visit one (25 vs 20, p=0.02) and ANC visit four (16 vs 10,
p<0.01).
Similar to health centres, the health post data indicates ANC visits
are probably recorded based on the timing of the visit rather than
the number of visits, although the rather high mean number of
women getting ANC visit in the irst trimester may indicate that data might be recorded diferently in diferent health posts. In some health posts a woman in her third trimester having a irst visit might be recorded as having ANC visit one, hence artiicially inlating the number of women receiving ANC in the irst trimester. With respect to targets, if on average a PHCU expects
44 pregnant women and on average 22 women actually had at
least once ANC visit, it indicates that 50% of expected pregnant
women are not receiving any ANC visits within their catchment
health post.
Registers at health centres were also reviewed for PNC provided
in the previous three months (Table 14A). According to national
Table 13B. Health post register review: services provided for pregnant women in the last three months
a N=236: 4 Health posts that did not record ANC 1not included (2% of early 1% of late implementers) b N=220: 20 Health posts that did not record ANC 2 not included (8% of early 8% of late implementers) c N=219: 21 Health posts that did not record ANC 3 not included (9% of early 8% of late implementers) d N=231: 9 Health posts that did not record ANC 4 not included (4% of early 3% of late implementers) e N=239: 1 Health post that did not record live births not included
*p<0.05 for test of diference between early and late implementers
EARLY
IMPLEMENTERS
LATE
IMPLEMENTERS
TOTAL
N=140 N=100 N=240
MEAN MEAN MEAN
Expected services
Pregnancies in health post catchment area* 47 39 44
Provided services
ANC
Visit one (1st trimester) * a 25 20 22
Visit two (2nd trimester) b 13 11 12
Visit three (3rd trimester) c 10 9 19
Visit four (3rd trimester) * d 16 10 14
Number of live births e 24 17 21
40
Table 14B. Health post register review: services provided for newborns in the last three months
Table 14A. Health centre register review: services provided for newborns in the last three months
EARLY
IMPLEMENTERS
LATE
IMPLEMENTERS
TOTAL
N=70 N=47 N=117
MEAN MEAN MEAN
Newborn PNC
Day one 86 80 84
Day three a 7 14 10
Day seven *a 5 12 7
Day one PNC based health centre deinition of irst PNCCare provided at the facility prior to
discharge
116 85 104
Care provided after discharge and within
24 hours of delivery
44 75 57
Birth asphyxia treatment* <1 1 <1
a N=110: 7 Health centres that did not record PNC not included (4% of early 9% of late implementers)
*p<0.05 for test of diference between early and late implementers
a N=236: 4 health posts that did not record PNC 1 not included (1% of early 2% of late implementers) b N=228: 12 health posts that did not record PNC 2 not included (1% of early 10% of late implementers) c N=227: 13 health posts that did not record PNC 3 not included (2% of early 10% of late implementers)
EARLY
IMPLEMENTERS
LATE
IMPLEMENTERS
TOTAL
N=140 N=100 240
MEAN MEAN MEAN
Newborn PNC
Day one a 15 8 12
Day three b 12 7 10
Day seven c 10 7 9
41
7. Three PHCUs in North Gondar zone (late implementing zone) were not visited due to civil unrest. More health posts in other PHUCs
of the same zone were visited to ensure the desired sample size.
8. Edir: Traditional community organisation whose members assist each other during the mourning process
guidelines, three PNC visits should be made in the irst week of a newborn’s life: PNC one within 24 hours of delivery; PNC two
on day three post-delivery; and PNC three on day seven post-
delivery. Similar to ANC visits, misclassiication of record keeping of PNC visits may occur if they are recorded based on the timing
of the visits versus the actual number of visits. For example, a
newborn visited for the irst time on day seven, might have the visit recorded as PNC visit three.
At the health centre level, on average 84 newborns were provided
with a day one visit, 10 with a day three visit and 7 with day seven
visit. We also looked at the PNC data based on how health centres
deine a day one visit. Among those facilities that consider a day one visit as any care provided to the mother and newborn during
their stay at the facility after delivery, the mean day one PNC
increased to 104 and was higher in early implementing areas.
When looking at PNC among facilities that deine the day one visit as any care provided to the mother and newborn after their
discharge and within 24 hours of delivery, the mean number
drops to 57 and is smaller in early implementing areas. This
indicates that the level of day one PNC coverage is dependent on
diferences in deinition.
If on average a PHCU had 133 deliveries and on average 84
newborns actually had PNC within 24 hours, this indicates that
63% were provided with their irst PNC at the health centre. Health centres recorded on average less than one treatment for
birth asphyxia in the previous three months.
Similar PNC data for health posts are shown in Table 14B. On
average 12 newborns were provided with PNC on day one, 10 on
day three and 9 on day seven.
At the health post level, there were a total of 5,069 (3,384 in early
and 1,685 in late implementing areas) recorded births in the last
three months. In the same time period health posts had recorded
total 43 neonatal deaths, of which 20 were in early implementing
and 23 in late implementing areas, making the overall proportion
of recorded deaths to be 0.8% (0.6% in early and 1.4% in late
implementing areas).
As shown in the footnotes of Tables 13 and 14, there were some
missing data from registers. We checked the quality of record
keeping with PHCU to see if health centres with missing data also
had health posts with missing data. However, most of their health
posts had recorded ANC and PNC visits, indicating missing data
was not a systematic issue at the health post level within a PHCU.
“SIMILAR TO ANC VISITS, MISCLASSIFICATION OF
RECORD KEEPING OF PNC VISITS MAY OCCUR IF
THEY ARE RECORDED BASED ON THE TIMING OF
THE VISITS VERSES THE ACTUAL NUMBER
OF VISITS.”
42
HEW visits family to wash the newborn baby.
© Paolo Patruno Photography/IDEAS 2015
43
Under the CBNC job aids section we provide information
on the availability of registers, administrative materials and
forms. We explore CBNC drugs supply with respect to the
availability of gentamycin and amoxicillin at the health centre
intended for supplying health posts. In the referral linkages
section we assess if the referral system for young infant care
from health posts to health centres is working. We also
assess the level of referral from WDA leaders to HEWs.
CBNC JOB AIDS
This survey observed the availability of job aids, further
deined in Box 2, necessary to provide MNH care (Table 15A). We observed IMNCI registers, chart booklets and
health management information system (HMIS) forms in
over 95% of facilities. Around 85% had PNC registers, stock
card/bin card, request/re-supply forms and vaccination
cards. Only three-quarters had a family health card, with the
proportion being higher among early implementers (87%
vs 60%, p<0.01). Availability of supervision checklist was
observed in 79% of all health centres and was higher among
early implementers (87% vs 66%, p=0.01).
A similar assessment of job aids and administrative forms
at the health post level is shown in Table 15B. Chart booklet
and iCCM registers (0-2 months) were available in 99% of
health posts and 97% had copies of the family health card.
Ninety percent had PNC registers and 85% had vaccination
cards and the proportion was higher in early implementing
areas (90% vs 79%, p=0.02). There was a relatively low
availability of stock card/bin card, request and re-supply
forms and HMIS forms (45%, 55% and 72%, respectively).
A smaller proportion of early implementing areas had HMIS
forms (64% vs 84%, p<0.01). In addition, 98% of health posts
4. HEALTH SYSTEM INTEGRATION WITHIN THE PHCU FOR QUALITY CBNC SERVICES
This chapter assesses how well the PHCU
level health system is integrated to provide
CBNC services.
CHAPTER SECTIONS
1. CBNC job aids
2. CBNC drugs supply
3. CBNC referral linkages
44Table 15A. Health centre: observation of CBNC job aids
Table 15B.Health post: observation of CBNC job aids
EARLY
IMPLEMENTERS
LATE
IMPLEMENTERS
TOTAL
N=70 N=47 N=117
% % %
IMCI registration book (0-2 months) 97 94 96
Chart booklet 99 94 97
Family health card* 87 60 76
Pregnant woman and outcome registration book 86 85 86
PNC register 84 92 87
Stock card/bin card* 90 75 84
Vaccination cards 84 89 86
Request and re-supply forms 87 85 86
HMIS forms 99 98 98
Supervision checklist* 87 66 79
*p value <0.05 for test of diference between early and late implementers
*p value <0.05for test of diference between early and late implementers
EARLY
IMPLEMENTERS
LATE
IMPLEMENTERS
TOTAL
N=140 N=100 N=240
% % %
iCCM registration book (0-2 months) 100 98 99
Chart booklet 99 99 99
Family health card 98 96 97
PNC register* 94 85 90
Stock card/bin card 54 42 45
Vaccination cards* 90 79 85
Request and re-supply form 51 61 55
HMIS forms* 64 84 72
Additional materials
ANC register 94 91 93
Delivery register 81 81 81
Family folders 99 97 98
45 had family folders, although the survey did not assess if the forms
were illed and up-to-date.
Job aids and forms provided to WDA leaders are shown in
Figure 13. Eighty-six percent of WDA leaders had a family
health card, with the proportion being slightly higher among
early implementing area WDA leaders (90% vs 80%, p=0.03).
WDA leaders’ understanding of the content of the family health
card is further presented in the Knowledge section of Chapter
5: Potential of health workers and volunteers to deliver quality
CBNC services. Data collection forms were available among 39%
of WDA leaders.
CBNC DRUGS SUPPLY
HEWs are provided with a starter kit at training that includes
gentamycin (20 mg/2ml) and amoxicillin dispersible tablets
(125 mg or 250 mg). The starter kit is intended to sustain service
delivery for up to 12 months.
Box 2. CBNC job aids
1. IMNCI and iCCM registration books: registers used for classifying, treating
and keeping record of sick newborns
at the health centre and health post, respectively.
2. Chart booklet: guide used for classifying and treating sick newborns.
3. Family health card: MNCH behaviour change job aid used by HEWs and WDA
leaders to educate on
key MNH messages.
4. Pregnant women and outcome registration book: record of pregnant
women and their delivery outcomes
(e.g. type of delivery, complications encountered…etc.).
5. PNC register: record of PNC visits 1, 3, 7 and 42 days.
6. Stock card/bin card: drug inventory system.
7. Vaccination cards: record of primary vaccination and booster doses for child.
8. Request and re-supply forms: forms used for replenishing drugs.
9. HMIS forms: forms for routine data collection on facility provided services.
10. Supervision checklist: used to monitor and assess health posts’ activities,
services, supplies and coverage
of target indicators.
11. Family folder: a family-centered information collection tool for integrated health
service delivery by HEWs.
12. ANC register: record of ANC visits made during pregnancy.
46Figure 13. Health post: family health card available with WDA leaders
Figure 14A. CBNC drug supply at the health centre: observed supply of gentamycin 20mg/2ml in the
last three months*
Figure 14B. CBNC drug supply at the health centre: observed availability of amoxicillin (125mg and
250 mg dispersible tablet as well as 125 mg/5ml syrup) in the last three months
*p value <0.05 for test of diference between early and late implementers
*p value <0.05 for test of diference between early and late implementers
0
20
40
60
80
100
Late implementers (n=47)Early implementers (n=70)
Stock-out with
no replenishment
Stock-out despite
replenishment
Drug replenished
after stock-out
No stock-out
No.
hea
lth ce
ntre
s
36
9 132
2030 31
59
0
20
40
60
80
100
Late implementers (n=47)Early implementers (n=70)
Stock-out with
no replenishment
Stock-out despite
replenishment
Drug replenished
after stock-out
No stock-out
No.
of h
ealth
cent
res
7785
16 9 6 4 1 2
0
20
40
60
80
100
Late implementers (n=100)Early implementers (n=140)
% o
f WDA
lead
ers
8090
Drug available on day of survey Drug unavailable on day of survey
Drug available on day of survey Drug unavailable on day of survey
47 This study assessed the availability of these drugs at the health
centre level for resupplying health posts. A quarter of health
centres had gentamycin on the day of the survey with no stock-out
in the last three months and 8% had it on the day of the survey
despite reporting stock-out at some point in the three months
preceding the survey. Twenty-four percent of health centres
had no gentamycin on the day of the survey despite having the
drug replenished at some point in the previous three months
and 43% had no gentamycin for at least three months. Overall,
75% of health centres had experienced stock-out of gentamycin
20mg/2ml at some point in the previous three months. The
reason for this high level of stock-out could be that health centres
are encouraged to pass this drug to health posts rather than
retain it at their facility. The availability of gentamycin by early
and late comparison areas is shown in Figure 14A.
Similarly, 80% of health centres had some form of amoxicillin
(125 mg/250 mg dispersible tablet and or 125mg/5ml syrup) on
the day of the survey with no stock-out in the last three months
and 13% had it on the day of the survey despite reporting stock-
out at some point in the three months preceding the survey. Five
percent of health centres had no form of amoxicillin on the day of
the survey, despite having the drug replenished at some point in
the previous three months, and 2% had no amoxicillin for at least
three months. Overall 20% of health centres had experienced
stock-out at some point in the last three months. The availability
of any form of amoxicillin by early and late comparison areas is
shown in Figure 14B.
Within a woreda, drugs procured by Pharmaceuticals Fund
and Supply Agency are normally distributed from woreda
health oice to health centres and inally to health posts. For the CBNC programme however, drugs for the treatment of VSD
were procured by UNICEF, as amoxicillin dispersible tablet and
gentamycin 20mg/2ml were not part national essential medicine’s
list at the start of CBNC programme. To ensure immediate service
delivery, drugs were distributed to HEWs at end of their CBNC
training. In this survey, we assessed who was directly providing
drugs to health centres for replenishing health posts. Of those
receiving gentamycin and amoxicillin over half were supplied
directly by woreda health oice with the rest being supplied mainly by implementing partners. A smaller proportion of early
implementing areas were supplied by woreda health oices for both gentamycin (40% vs 64%) and amoxicillin (52% vs 70%).
REFERRAL AND SERVICE DELIVERY LINKAGE
In this section we will explore data abstracted from 0-2 month
IMCNI registers at health centres, as well as 0-2 month CBNC/
iCCM registers at health posts. We present data on diagnosis,
treatment and referrals of young infants. Mechanisms for referral
between health posts and health centres are also assessed. In
addition, we also look at referrals from community to HEWs, via
the WDA leaders.
IMNCI and CBNC/iCCM register review
IMNCI registers at health centres were reviewed and information
on 0-2 month old young infants seen in the three months
preceding the date of the survey (July-September 2015) were
collected. A total of 825 young infants were seen across 104
health centres. The remaining 13 (11%) health centres (5 in early
and 8 in late implementing areas) did not have any records of 0-2
month infants seen in the previous three months.
Similarly, at the health post level, 0-2 CBNC/iCCM registers were
reviewed and a total of 428 young infants (289 in early and 139
in late implementing areas) had been seen in 194 health posts in
the last three months (July-September 2015). The remaining 46
(19%) health posts (13 in early and 33 in late implementing areas)
had no information recorded on sick babies in the speciied time. We further looked at the data to see if these 46 health posts were
from the PHCUs where the health centres had no recoded data
on sick young infants. However, only a few (9 out of the 46) of
the health posts were from the 13 health centres with missing
records on sick babies. This shows that missing records were not
systematic at the PHCU level.
48
Table 16A. Health centre IMNCI register: review of record completeness & content in last three months
a 7 missing records for age of baby (4 from early and 3 from late implementing areas) b 86 missing data for weight of baby (22 from early and 64 from late implementing areas) c 305 missing (97 from early and 208 from late implementing areas) d 133 missing (35 from early and 98 from late implementing areas)
*p value <0.05 for test of diference between early and late implementers
EARLY
IMPLEMENTERS
LATE
IMPLEMENTERS
TOTAL
N=378 (%) N=447 (%) N=825 (%)A.
Com
plet
enes
s of
reco
rd
First and last name 100 100 100
Address 100 100 100
Date of visit 100 100 100
Age of baby 99 99 99
Gender of baby 100 100 100
Weight of baby at birth 100 100 100
Baby weight * 94 86 90
Gestational age in weeks 100 100 100
Temperature of baby * 91 78 84
Respiratory rate of baby* 74 53 63
Signs and symptoms of baby* 88 98 93
Disease classiication * 74 90 83
B. R
ecor
ded
info
rmat
ion
Age of baby in weeks (mean) a
0-1 week 14 15 15
2-4 weeks 51 53 52
5-8 weeks 34 32 33
Gender of baby
Male 54 53 53
Female 46 47 47
Birth weight of baby*
<1500g 0 <1 <1
1,500-2500 g 1 1 1
>= 2500 15 17 16
Unknown 84 81 83
Weight of baby (mean) b* 4254 4118 4183
Gestational age in weeks
<32 weeks 0 1 <1
32-36 weeks 2 1 1
>= 37 weeks 29 26 27
Unknown 69 72 71
Respiratory rate of baby
60 breaths/min or more* c 21 30 25
Temperature d
Low (<35.5 °C) 4 5 4
Normal (35.5-37.5 °C) 89 87 88
High (>37.°C) 7 9 8
49 Health centre IMNCI register review
Table 16A shows the completeness of the recorded data in the
IMNCI registers as well as the recorded information pertaining
to background information and initial assessment of the young
infants receiving care at the health centre. Data that were
recorded were complete for some (name, address and date
of visit) and missing for others (age, weight, temperature,
respiration rate, signs and symptoms, and disease classiication). Of these, the most amounts of missing data were for respiratory
rate (37% missing), followed by disease classiication (17% missing) and temperature (16% missing). Compared with early
implementers, a smaller proportion of late implementers had
recorded baby’s weight, temperature and respiratory rate, while
a higher proportion had recorded signs and symptoms, and
disease classiication.
According to 0-2 month IMNCI registers, on average there were
7.5 sick infants seen across the 117 health centres (5.4 in early
and 9.5 in late implementing areas). As mentioned earlier, a
total of 825 young infants were seen across 104 health centres,
with 378 being in early and 447 in late implementing areas. The
remaining 13 (11%) health centres had no recorded data in their
0-2 month IMNCI registers for the three months preceding the
date of the survey. The majority (52%) of babies were between
the ages of 2-4 weeks, while 15% were a week old or less. Fifty-
three percent were males. Birth weight was unknown for the
majority of babies (83%) seen in the last three months and was
similar by implementation area. Mean weight on the day of
consultation was 4,183 grams.
High temperature (>37.5 °C) was recorded in 8% of young
infants and 25% had a breath count of 60/min or more. Of the
131 babies that had 60 breaths/min or more recorded, 81 (62%)
were then classiied as having fast breathing. Of the 56 young infants that had a high temperature recorded, 36 (64%) were
classiied as having fever. Among those that had normal breath rate and temperature, the majority were classiied correctly as not having these signs (98% and 84%, respectively).
The overall disease classiications are shown in Table 16B. Among all the babies diagnosed at the health centre level in the last three
months, about a quarter of were classiied as having a VSD and a similar proportion as having a local bacterial infection. A VSD for
this analysis included cases classiied as VSD, sepsis, pneumonia and acute febrile illness. Only 4% had a feeding problem.
Treatment provided to those classiied as having a particular disease is also shown in Table 16B. Among those that were
classiied as having a VSD, 15% received a combination of gentamycin and ampicillin, 6% were given a combination of
gentamycin and amoxicillin, and 1% a combination of amoxicillin
and ampicillin. Forty-three percent were given amoxicillin only,
14% were given gentamycin only, 3% were given ampicillin
only and 5% were given another kind of antibiotic only. Of the
total 190 cases (73 in early and 117 in late implementing area),
14% (n=27, 16 were in early and 11 were in late implementing
areas) of young infants classiied as having a VSD did not get any antibiotics and of these 48% (n=13, 11 in early and 3 in late
implementing areas) were recorded as being referred to a higher
level facility for treatment.
For local bacterial infection, 85% were provided with amoxicillin
and another 7% were provided with other antibiotics. Of the
5 young infants recorded as having dehydration, 80% were
provided with ORS and 20% with zinc.
Among the 24 VSD cases that got treated with gentamycin at
the health centre, 71% were recorded as completing treatment.
Among all VSD cases treated at the health centre, the vast majority
(69%) were recorded as having an unknown outcome and this
was similar between the two implementation areas.
Health post CBNC/iCCM register review
Table 17A shows the completeness of the recorded data in
the CBNC/iCCM registers as well as the recorded information
pertaining to background information and initial assessment of
the young infants receiving care by HEWs. Similar to the IMNCI
50
Table 16B. Health centre IMNCI register: disease classiication and treatmentEARLY
IMPLEMENTERS
LATE
IMPLEMENTERS
TOTAL
N=378 (%) N=447 (%) N=825 (%)A.
Dise
ase c
lassii
catio
nVSD* a 19 26 23
Severe dehydration 0 0 0
Some dehydration <1 <1 <1
Local bacterial infection 27 21 24
Jaundice <1 0 <1
Severe jaundice 0 0 0
Feeding problem or low weight* 5 4 4
Very preterm and/or very low birth weight <1 0 <1
Preterm and/or low birth weight 0 0 0
B. Tr
eatm
ent a
mong
thos
e clas
siied
with
dise
ase
Treatment for VSD*
Gentamycin and ampicillin 22 10 15
Amoxicillin and gentamycin 11 3 6
Amoxicillin and ampicillin 0 1 1
Gentamycin only 16 13 14
Amoxicillin only 26 53 43
Ampicillin only 1 3 3
Other antibiotic only 1 7 5
No antibiotic 22 9 14
Treatment of other diseases
Amoxicillin for local bacterial infection 87 84 85
Other antibiotics for local bacterial infection b 4 9 7
ORS for dehydration 100 67 80
Zinc for diarrhoea 50 0 20
C. R
efer
ral Sick newborn referred* 10 5 8
VSD cases refereed* 44 16 27
D. V
SD tr
eatm
ent c
ompl
etio
n an
d ou
tcom
e Gentamycin completion at health centre among
VSD diagnosed cases c
82 43 71
Outcome of all VSD cases
Health improved 37 25 30
Same >1 0 <1
Died >1 0 <1
Unknown 60 75 69
a Includes VSD, sepsis, pneumonia and acute febrile illness b Co-trimoxazole and cloxacillin c Among VSD cases not referred to higher facility
*p value <0.05 for test of diference between early and late implementers
51
. Health post iCCM register: review of record completeness & content in last three months
EARLY
IMPLEMENTERS
LATE
IMPLEMENTERS
TOTAL
N=289 (%) N=139 (%) N=428 (%)A.
Com
plet
enes
s of
reco
rd
First and last name 100 100 100
Address 100 100 100
Date of visit 100 100 100
Age of baby 99 99 99
Gender of baby 100 100 100
Weight of baby at birth 100 100 100
Baby’s weight 99 98 99
Gestational age in weeks 100 100 100
Temperature of baby 97 97 97
Respiratory rate of baby* 88 63 80
Signs and symptoms of baby 100 99 99
Disease classiication of baby* 56 80 64
B. R
ecor
ded
info
rmat
ion
Age of baby in weeks (mean) * a
0-1 week 46 34 42
2-4 weeks 33 36 34
5-8 weeks 21 30 24
Gender of baby
Male 56 54 55
Female 44 46 45
Birth weight of baby*
<1500g <1 0 <1
1,500-2500 g 1 4 2
>= 2500 82 50 72
Unknown 17 49 27
Weight of baby (mean) * b 3723 3535 3662
Gestational age in weeks
<32 weeks 0 1 <1
32-36 weeks 3 4 4
>= 37 weeks 57 51 55
Unknown 40 44 41
Respiratory rate of baby
60 breaths/min or more * c 16 32 20
Temperature d
Low (<35.5°C) 3 7 5
Normal (35.5-37.5 °C) 91 84 89
High (>37°C) 5 8 6
a 5 missing data for age of baby (4 from early and 1 from late implementing areas) b 5 missing data for weight of baby (2 from early and 3 from late implementing areas) c 12 missing data for respiratory rate of baby (8 from early and 4 from late implementing areas) d 86 missing data for temperature of baby (35 from early and 51from late implementing areas)
*p value <0.05 for test of diference between early and late implementers
52
Table 17B. Health post iCCM register review: recorded treatment for sick 0-2 newborns in last three months
EARLY
IMPLEMENTERS
LATE
IMPLEMENTERS
TOTAL
N=289 (%) N=139 (%) N=428 (%)A.
Dise
ase c
lassii
catio
n
VSD* 17 27 20
Severe dehydration 0 <1 <1
Some dehydration 1 4 2
Local bacterial infection 18 20 19
Jaundice 0 <1 <1
Severe jaundice 0 >1 <1
Feeding problem or low weight 12 14 13
Very Preterm and/or very low birth weight <1 0 <1
Preterm and/or low birth weight <1 <1 <1
B. Tr
eatm
ent a
mong
thos
e clas
siied
with
dise
ase Treatment for VSD*
Amoxicillin and gentamycin 45 35 41
Gentamycin only 37 16 28
Amoxicillin only 10 46 26
No antibiotic 8 3 6
Treatment for other diseases
Amoxicillin for local bacterial infection 96 93 95
ORS for dehydration 100 100 100
Zinc for dehydration 100 100 100
Nutritional counselling for feeding problem 44 74 55
C. R
efer
ral Sick newborn referred* 10 19 13
VSD cases refereed 43 51 46
D. V
SD tr
eatm
ent c
ompl
etio
n an
d ou
tcom
e Gentamycin completion at health post among
VSD diagnosed cases a
82 77 80
Outcome of all VSD cases
Health improved 76 81 77
Same 0 5 2
Died 2 5 3
Unknown 22 8 16
a Among VSD cases not referred to higher facility
*p value <0.05 for test of diference between early and late implementers
53 records, some data were recorded with 100% completeness (age,
name and address), while others had missing data (age, weight,
temperature, respirator rate, signs and symptoms, and disease
classiication). Of these, the most amounts of missing data were for disease classiication (36% missing), followed by respiratory rate (20% missing). The proportion of missing data on disease
classiication was higher in early implementing areas, while the reverse was observed for missing data on respiratory rate. This
level of missing data on disease classiications undermines the CBNC programme.
According to 0-2 month iCCM registers, on average there were
1.8 sick children seen across the 240 health posts (2.1 in early
and 1.4 in late implementing areas). As mentioned earlier, a
total of 428 young infants were seen across 194 the health posts,
with 289 being in early and 139 in late implementing areas. The
High temperature (>37.5 degrees Centigrade) was recorded in
6% of babies and 20% had a breath count of 60/min or more. Of
the 68 newborns that had recorded 60 breaths/min or more, 56
(82%) were classiied as having fast breathing. Of the 26 infants that had a recorded high temperature, 17 (65%) were classiied as having a fever. Among those that had normal breath rate and
temperature, the majority were classiied correctly as not having these signs (99% and 97%, respectively).
The overall disease classiications are shown in Table 17B. Among infants diagnosed at the health post level in the last three
months, about a ifth were classiied as having a VSD, 19% had a local bacterial infection and 13% had a feeding problem.
Treatment provided to those classiied as having a particular disease is also shown in Table 17B. Of the 86 (49 in early and 37
“THE IMPROVEMENT IN THE LEVEL OF MISSING
DATA ON DISEASE CLASSIFICATION IN FACILITY
REGISTERS WILL FACILITATE THE MONITORING
OF THE CBNC PROGRAMME.”
remaining 46 (19%) health posts had no recorded data in their
0-2 month iCCM registers for the three months preceding the
survey. The majority (42%) of babies were a week old or less,
while 34% were aged of 2-4 weeks. This is in contrast to the age
of infants seen at health centres, of which the majority were
2-4 weeks old. Fifty-ive percent were males. Birth weight was unknown in 27% infants seen in the last three months with the
proportion rising to about half in late implementing areas. Mean
weight on the day of consultation was 3,662 grams. Gestational
age was unknown for 41% of the infants and about 5% were born
before reaching 37 weeks.
in late implementing areas) VSD cases, 41% were provided with
both gentamycin and amoxicillin, while 28% were provided with
gentamycin only and 26% with amoxicillin only. The remaining
5 (6%) infants were referred to a higher facility without a pre-
referral dose of antibiotics.
For those identiied as having a local bacterial infection, 95% were provided with amoxicillin and for dehydration 100%
were provided with ORS and zinc. Nutritional counselling was
provided to the caregivers of 55% of infants identiied as having feeding problems.
54
Table 18. Referral linkages between health post and health centrea
a Information provided by health centre staf
*p value <0.05for test of diference between early and late implementers
EARLY
IMPLEMENTERS
LATE
IMPLEMENTERS
TOTAL
N=70 N=47 N=117
% % %
Use of referral form
Health centres receiving forms from health posts * 51 21 39
Use of government transport from health post to
health centre during last obstetric referral
67 58 63
Motorised transportation at health centre
Motorcycle* 49 30 41
Ambulance 13 13 13
Motorcycle and ambulance 13 9 11
None 51 66 57
Figure 15: Connectedness of referral system: infants that were referred from health post to health
centre who followed up on their referral
0
20
40
60
80
100
Late implementers (n=27)Early implementers (n=29)
% o
f ref
erre
d in
fant
s
0
14
55 Among those classiied as having VSD, 46% were referred to health centres. Among the 54% that received treatment at the
health post, 80% completed their gentamycin injection. Among all
VSD cases, 77% were recorded as having their health improved,
3% had died, and for 16% outcome was unknown.
Referral between health posts to health centres
Figure 15 shows the referrals between health post and health
centre. According to the 0-2 iCCM registers, 56 sick infants (29
from early and 27 from late implementation areas) were referred
from health posts, of which only four (7%) were cross-linked to
the referral health centre’s IMNCI register. All four were among
the 29 newborns referred from early implementing areas.
CBNC training covers the use of referral forms by HEWs when
referring sick newborns. Health centres were asked if they
receive referral forms from health posts for MNH care and 39%
reported that they do. Use of referral forms was higher among
early implementing areas (51% vs 21%, p<0.01). Availability of
motorised transport is also essential for referrals from health
post to health centre and in this study 13% of health centres
had their own ambulance. A motorcycle was available in 41%
of health centres, with the proportion being higher among early
implementers (49% vs 30%, p=0.04). Yet, 57% of health centres
had no motorised transport. About two-thirds reported that a
government owned vehicle was used for the most recent obstetric
referral from a health post to a health centre (Table 18). District
level information on the availability of functional ambulances
showed that all 30 visited districts had an ambulance. On average
districts had two ambulances and this was similar by early and
late implementing districts.
Referrals between WDA leaders and health posts
WDA leaders play a key role in the CBNC programme by referring
community members to the health post for MNH care. This
survey assessed WDA leaders’ ANC and PNC counselling activity in
the last six months, which primarily implies referral of pregnant
women and newborns to HEWs. ANC referral was high (84%).
About three-quarters provided PNC referral and the proportion
was higher among early implementers (88% vs 62%, p<0.001).
56
Under the training section, we explore training received
by health centre staf, HEWs and WDA leaders. In the knowledge section, we measure HEW and WDA leaders’
understanding of the CBNC protocol and lastly we present
their overall practice in the last three months.
TRAINING
To understand the quality of CBNC services provided at the
PHCU level, the midline survey assessed the level of training
provided to health centre staf, HEWs and WDA leaders. Findings are presented below.
Health centre staf
IMNCI trained staf at the health centre are important for providing appropriate treatment for sick newborns that are
referred from the community by HEWs, as well as those
that come directly to the health centre seeking care. CBNC
programme implementation intends to train two IMNCI
trained health centre staf members in CBNC. It also aims to train two additional staf members in both IMNCI and CBNC. In addition to improving the quality of care provided
at health centres and the referral linkages, these trained
staf members are integral for improving the quality of the support from the health centres to the health posts.
In this study, 111 (95%) facilities had an IMNCI trained
staf, with early implementing areas having 68 (95%) and late implementing areas having 43 (91%). Overall, there
were an average of two IMNCI trained staf members at each health centre and the majority of were nurses. Among
the 111 facilities, 22 (20%: 16% in early and 26% in late
implementing areas) reported that a staf member had
5. POTENTIAL OF HEALTH WORKERS AND VOLENTEERS TO DELIVER QUALITY CBNC SERVICES
This chapter presents the potential of
health workers and volunteers to deliver
CBNC services and contains three sections.
CHAPTER SECTIONS
1. Training
2. Knowledge
3. Practice
57
Table 19A. Health post: training received by HEWs on newborn health
Table 19B. Health post: HEW satisfaction with training
*p value <0.05 for test of diference between early and late implementers
EARLY
IMPLEMENTERS
LATE
IMPLEMENTERS
TOTAL
N=140 N=100 N=240
% % %
Status of trainings received at any point
CBNC 100 96 98
iCCM 100 97 99
*p value <0.05 for test of diference between early and late implementers
EARLY
IMPLEMENTERS
LATE
IMPLEMENTERS
TOTAL
N= 107 N=93 N= 200
% % %
Satisfaction with training* 78 47 64
Suggestion to improve training
Post training supervision 79 81 80
Further training 51 60 56
Practice sessions 48 52 50
Training aids 42 54 48
58left after being trained in IMNCI. These facilities reported that
on average one IMNCI trained staf member had left after being trained. Fifty-ive percent reported that the individual had been transferred to another health centre, 18% that they had been
promoted and 27% that they had moved to another organisation.
Three out of the 22 facilities (14%) that had reported staf turnover said they had replaced the person with another
trained staf member. All three facilities were in early implementing areas.
This study also assessed the availability of CBNC trained staf at health centres. Sixty-eight percent of health centres (70% in
early and 66% in late implementing areas) had CBNC trained
staf. Among the 80 health centres with CBNC trained staf, 19% (20% in early and 16% in late implementing areas) reported
that they had a staf member leave after being trained in CBNC. Seventy-three percent of these reported that the individual had
been transferred to another health centre, 7% that they had been
promoted and 13% that they had moved to another organisation.
None of the facilities replaced the person with another trained
staf member.
respect to HEW training within the PHCU were similar by in early
and late implementing areas.
HEW training
The success of the CBNC programme relies on early contact
of HEWs with newborns, so that they can provide PNC visits
at home or at the health post. HEWs are expected to support
appropriate care for newborns, including screening the newborn
for danger signs and referring those with a VSD, after providing a
pre-referral dose of amoxicillin and gentamycin. If referral is not
possible, HEWs treat the sick newborn at the health post level.
HEWs in this study were asked about the training they had
received in CBNC, iCCM and Integrated Refresher Training
on MNCH (Table 19A.) All HEWs in early and 98% in late
implementing areas had received CBNC training. Similarly,
100% of HEWs in early and 97% of HEWs in late implementing
areas had received iCCM training. Although Integrated Refresher
Training is annual, over a quarter of HEWs (39% of early and
11% of late implementing areas, p<0.001) had not received such
a training.
“HEALTH EXTENSION WORKERS ALSO ADDED
THAT MORE TRAINING PRACTICE SESSIONS...
AND ADITIONAL TRAINING AIDS WOULD
IMPROVE TRAINING OVERALL”
Health centres were asked about HEWs’ CBNC training and
turnover in their satellite health posts. Almost all facilities (98%,
n=115) reported that HEWs in their catchment health posts
had been provided with CBNC training. On average, health
centres had trained nine HEWs in CBNC. Among health centres
with trained HEWs, a quarter (n= 30) reported that HEWs had
left since getting the CBNC training. None of the health centres
replaced the vacancy with a CBNC trained HEW. Findings with
HEWs were asked about their level of satisfaction with the
training they had received in the last 12 months. Among those
that received CBNC, iCCM and Integrated Refresher Training
(n=200), only 64% were fully satisied (Table 19B). The level of satisfaction was much higher among early implementers (78%
vs 47%, p<0.001). The majority reported that a post training
supervision would improve their overall training. Around 50%
of HEWs also added that more training practice sessions (which
59 at times are omitted from the training sessions) and additional
training aids would improve their overall training.
WDA leaders’ orientation
As part of their Integrated Refresher Training, HEWs are trained
to orient WDA leaders to support rollout of MNCH services in the
community, including CBNC. Implementing partners do not play
a direct role in the training and supervision of WDA leaders. WDA
leaders are expected to counsel and carry out social mobilisation
activities to increase the knowledge, attitude and health seeking
behaviour of mothers. In addition, they are expected to notify
HEWs of pregnancies and births, visit newborns, refer sick
children to health posts, counsel families to follow-up on
referrals to health posts and health centres and also support
treatment compliance for sick newborns.
MNH training was provided to 83% of WDA leaders in the last
12 months and was similar between implementation areas.
Among those trained, over 90% had received training across the
continuum of care, including providing home visits, referring for
PNC care, educating on newborn danger signs and referring sick
newborns. Implementation areas were similar except for training
on use of the family health card and referring for PNC care,
where a greater proportion of early implementing area WDA
leaders reported receiving these trainings.
WDA leaders’ satisfaction with their newborn care orientation in
the last 12 months was also assessed. The majority (84%) were
satisied with their training, with satisfaction level being greater among early implementing area WDA leaders (87% vs 79%,
p=0.001).
KNOWLEDGE
In this section we present the assessment of HEW and
WDA knowledge on the diferent components of the CBNC programme. Speciically, for HEWs we assessed their knowledge on newborn general care, signs of newborn illness, management
of newborn illness and side efects of antibiotic use. For WDA leaders we assessed their knowledge on general MNH as well as
their understanding of the family health card.
HEWs’ unprompted knowledge of relevant CBNC components
According to government guidelines, HEWs are instructed to use
the iCCM chart booklet when assessing a newborn. The chart
booklet provides the speciic steps a HEW should follow when assessing and managing newborns. The knowledge section of
this survey however, assessed their unprompted knowledge of
newborn danger signs, classiication and treatments. As such, it is expected that if HEWs had accessed their chart booklet, they
are likely to have performed better than what is shown in the
following section.
HEWs’ knowledge: newborn general care
HEWs were asked about their knowledge on providing care in the
postnatal period. Table 20A shows their knowledge with respect
to the main components of the PNC one visit (within 24 hours of
delivery) and subsequent visits (on days 3, 7 and 42).
On PNC counselling, the majority of HEWs had knowledge on
the need to encourage mothers to breastfeed exclusively (75%).
However, more than half of HEWs did not cite advising the
caregiver to delay bathing, and the need for skin-to-skin contact
and cord care. Furthermore, only around a quarter of HEWs had
knowledge on the importance of educating families on hygiene
and recognising newborn danger signs. HEWs’ knowledge of
counselling done on PNC one visit was similar between early and
late implementing areas, except for skin-to-skin contact where
knowledge was higher among early implementing area HEWs.
With respect to activities that are needed to be carried out
by HEWs during the irst PNC visit, 68% mentioned checking newborn danger signs. Around 60% stated the need to measure
a newborn’s weight and temperature, which were both higher
among HEWs in late implementing areas. Knowledge of other
60Table 20A. HEWs’ knowledge (unprompted): newborn general care
*p value <0.05 for test of diference between early and late implementers
EARLY
IMPLEMENTERS
LATE
IMPLEMENTERS
TOTAL
N=140 N=100 N=240
% % %
1. Main components of irst PNC visit Counselling
Exclusive breastfeeding 78 70 75
Cord care 31 39 35
Washing hands before touching baby 30 19 25
Delay bathing 51 53 52
Skin-to-skin contact* 45 20 35
Danger sign recognition using family health card 26 20 23
Activity
Check for danger signs 69 67 68
Measure weight* 68 50 60
Measure temperature* 65 51 59
Provide cord care 43 44 43
Vaccinate for polio and BCG 43 40 42
Apply TTC eye ointment 31 21 27
Check for congenital abnormalities 11 17 13
2. Main components of subsequent PNC visit
Counselling
Exclusive breastfeeding 82 80 81
Cord care 31 39 35
Activity
Check danger signs 71 59 66
Measure weight * 61 43 55
Assess breastfeeding 89 82 86
Ensure baby is kept warm* 53 31 44
Vaccination 54 60 65
61
activities, including vaccination (polio and BCG) and providing
cord care were mentioned by less than half of all HEWs.
For subsequent PNC visits, over 80% of HEWs had knowledge on
exclusive breastfeeding counselling and checking breastfeeding.
Two-thirds of HEWs mentioned assessing newborn danger signs.
Overall, knowledge of the assessment and education on
breastfeeding during PNC visits was relatively high. However,
knowledge of ensuring that the newborn is kept warm and cord
care, across PNC visits was low. Knowledge of assessing newborn
danger signs during irst and subsequent visits was not cited by around a third of HEWs.
HEWs’ knowledge on signs of newborn illness: VSD
HEWs’ knowledge on newborn signs of illness is shown
in Table 20B. For VSD, over 70% of cited convulsions and
feeding problems as danger signs. Over half mentioned high
temperature, fast breathing and limited movement. However,
severe chest in-drawing and low temperature were cited by less
than half of the HEWs. A higher proportion of early implementing
area HEWs cited severe chest in-drawing (54% v s26%, p<0.001),
convulsions (82% vs 66%, p<0.01), limited movement (60% vs
39%, p<0.01) and high temperature (74% vs 60%, p=0.03)
compared with HEWs in late implementing areas.
HEWs’ knowledge on signs of newborn illness: local bacterial infection
For local bacterial infection over 70% of HEWs had knowledge
of red umbilicus and skin pustules as signs, and 65% cited
umbilicus that was draining pus. A greater proportion of early
implementing area HEWs cited red and pus draining umbilicus
compared with late implementing area HEWs.
HEWs’ knowledge on signs of newborn illness: feeding problems
With respect to feeding problems, 80% of HEWs had knowledge
of newborns’ proper attachment to the breast. Around 70% cited
inefective suckling and lack of exclusive breastfeeding. The rest of the symptoms were known by less than half of the HEWs,
with only 17% mentioning thrush. A greater proportion of early
implementing area HEWs had more knowledge on four out of the
seven signs of feeding problems, where the diference reaches statistical signiicance (p<0.05).
HEWs’ knowledge on signs of newborn illness: jaundice and severe jaundice
For jaundice, 79% of HEWs mentioned yellow skin while 68%
mentioned yellow eyes. With respect to severe jaundice, around
three-quarters of HEWs cited yellow palms and soles as signs.
However, around two-thirds did not know the signs of severe
jaundice with respect to the age of a newborn (jaundice in
those less than 24 hours and those over 14 days), although
the proportion was higher (over 50%) among HEWs in early
implementing as compared with those in late implementing
(<20%) areas.
HEWs’ knowledge on the management of newborn illness: VSD
HEWs’ knowledge on the management of newborn illness is
shown in Table 20C. For VSD, almost all HEWs knew the need to
refer urgently. Counselling the mother to continue breastfeeding
was mentioned by 60% of HEWs. Around 75% cited the need to
provide a pre-referral dose of amoxicillin and gentamycin. Fifty-
“FOR VERY SEVERE
DISEASES ALMOST ALL
HEALTH EXTENSION
WORKERS KNEW
THE NEED TO
REFER URGENTLY.”
62Table 20B. HEWs’ knowledge (unprompted): signs of newborn illness
*p value <0.05 for test of diference between early and late implementers
EARLY
IMPLEMENTERS
LATE
IMPLEMENTERS
TOTAL
N=140 N=100 N=240
% % %
1. Very severe disease
Convulsions* 82 66 75
Stopped or reduced feeding 75 69 73
Temperature greater than 37.5* 74 60 68
Fast breathing 69 57 64
No or limited movement* 60 39 51
Severe chest in-drawing* 54 26 43
Temperature less than 35.5 45 38 42
2. Local bacterial infection
Red umbilicus* 82 59 73
Skin pustules 79 76 78
Umbilicus draining puss* 74 53 65
3. Feeding problem
Not well attached to breast 81 78 80
Receives other foods or drinks 71 72 71
Not suckling efectively 74 64 70
Less than 8 breastfeeds in 24 hours* 68 47 59
Switching to another breast before one is emptied* 59 33 48
Underweight for age* 55 35 47
Thrush* 26 4 17
4. Jaundice
Yellow skin 78 81 79
Yellow eyes 72 62 68
5.Severe jaundice
Palms yellow 83 73 79
Soles yellow* 80 66 74
Jaundice in newborn age 14 days or more* 53 18 38
Jaundice in newborns of age less than 24 hours* 51 15 36
63
*p value <0.05 for test of diference between early and late implementers
Table 20C. HEWs’ knowledge (unprompted): management of newborn illness
EARLY
IMPLEMENTERS
LATE
IMPLEMENTERS
TOTAL
N=140 N=100 N=240
% % %
1. Very severe disease
Refer urgently to higher facility 92 94 93
Pre-referral dose of amoxicillin* 78 66 73
Pre-referral dose of gentamycin* 81 68 75
Continue to breastfeed 65 53 60
Provide 7 day amoxicillin if referral is not possible* 54 33 45
Treat with 7 day gentamycin if referral is not possible* 51 36 45
2. Local bacterial infection
Give amoxicillin for 5 days* 85 63 76
Follow-up care on 2ndday* 49 19 36
3. Feeding problem
Advise mother to breastfed often and as long as
infant wants*
91 80 87
Teach mother correct positioning and attachment 77 76 77
Educate on exclusive breastfeeding* 76 62 70
Follow-up on feeding problem* 50 29 41
Teach mother to treat thrush at home* 29 7 20
Follow-up on thrush cases in two days* 19 5 13
Follow-up on underweight for age cases in 14 days* 16 7 13
4. Jaundice
Breastfeed more frequently* 76 63 70
Cover baby well* 66 42 56
Advice mother to return if the situation gets worse 35 26 31
Expose child to sunshine * 40 20 32
Follow-up in two days* 39 14 28
5. Severe jaundice
Refer urgently* 96 87 92
Breastfeed more frequently* 74 53 65
Keep baby warm* 58 24 44
64
6. Moderate dehydration
Give ORS* 100 91 96
Zinc for 10 days* 94 81 89
Give breast milk 83 79 81
Breastfeed more frequently 83 79 81
Keep infant warm* 44 14 31
Follow-up in 2 days* 53 21 40
7. Severe dehydration
Refer urgently* 96 86 92
Give ORS on the way to facility 79 74 77
Breastfeed more frequently* 72 59 67
Advice mother to keep newborn warm* 53 19 39
Give irst dose of amoxicillin 9 13 10
8. Low birth weight and premature (1.5-2.5 kg/32-27 weeks of gestation)
Educate on breastfeeding 89 89 89
Make sure baby is warm 78 77 78
Monitor ability to breastfeed* 80 68 75
Monitor baby for the irst 24 hours* 34 16 27
Education on cord care* 32 18 26
9. Very low birth weight(less than 1.5kg)
Refer urgently with mother to hospital 84 84 84
Monitor ability to breastfeed 68 73 70
Cover baby well including head 68 63 66
Continue feeding with expressed breast milk* 71 54 64
Hold close to mother 57 44 52
Table 20C. HEWs’ knowledge (unprompted): management of newborn illness, continued
65 ive percent however, did not cite the need to treat with these two drugs for seven days if referral is not possible. Overall,
HEWs’ knowledge on the management of newborn illness with
gentamycin and amoxicillin was higher in early implementing
areas.
HEWs’ knowledge on management of newborn illness:
local bacterial infection
For local bacterial infection, 76% of HEWs knew to treat the
newborn with amoxicillin for ive days. However, only 36% mentioned the need to provide follow-up care.
HEWs’ knowledge on the management of newborn illness: feeding
problems
For the management of breastfeeding problems, advice on
frequent breastfeeding, educating on proper attachment and
exclusive breastfeeding were mentioned by 87%, 77% and
70% of HEWs, respectively. Other components of managing a
newborn with feeding problems were mentioned by less than
half of HEWs. HEWs from early implementing areas showed
better overall knowledge on the management of newborns with
feeding problems.
HEWs’ knowledge on the management of newborn illness: jaundice and severe jaundice
For management of jaundice, 70% mentioned breastfeeding
more frequently. Less than one-third cited follow-up care and
exposing newborn to sunshine. For severe jaundice almost all
(92%) mentioned the need to refer urgently. However, only 65%
and 44% mentioned the need to breastfeed more frequently
and keep baby warm, respectively. A larger proportion of HEWs
from early implementing areas had better knowledge on the
management of both jaundice and severe jaundice.
HEWs’ knowledge on the management of newborn illness: moderate
and severe dehydration
For moderate dehydration, HEWs had good knowledge on the
need to treat with ORS (96%) and zinc (89%). Over 80% also
mentioned giving breast milk and feeding more frequently. For
severe dehydration over 90% of HEWs knew to refer urgently.
HEWs’ knowledge on the management of newborn illness: very low/low
birth weight and premature
For low birth weight and premature newborns, almost 90%
mentioned educating on breastfeeding, with around 75% stating
the need to monitor baby’s feeding and ensure that the newborn
is kept warm. For newborns less than 1.5kgs, 84% stated the
need to refer urgently and 70% cited the need to monitor the
newborn’s ability to breastfeed. Make sure baby is warm.
WDA leaders’ knowledge of relevant CBNC components
As mentioned previously, it is the HEWs’ responsibility to engage
WDA leaders to support uptake MNCH services in the community,
including CBNC. HEWs provide the necessary orientation to WDA
leaders on MNCH issues of importance. This section presents
WDA knowledge on relevant CBNC components based on the
orientation that is provided to them by HEWs.
WDA leaders’ knowledge: newborn care
Table 21 shows WDA leaders’ knowledge on newborn health
care. WDA leaders were asked about the timing of PNC visits
and 50% or less knew that visits should take place day one,
three, seven and 42. Only 14% of WDA leaders knew the timing
of all three visits that take place in the irst week of life, and the proportion dropped to 4% when including day 42. These data are
shown by implementation area in Figure 16.
With respect to components of PNC counselling, over half of
WDA leaders mentioned promotion of breastfeeding, advice
on vaccination and keeping the baby warm. However, less than
66Table 21. WDA leaders’ knowledge (unprompted): MNH
*p value <0.05 for test of diference between early and late implementers
TOPICS COVERED EARLY
IMPLEMENTERS
LATE
IMPLEMENTERS
TOTAL
N=140 N=100 N=240
% % %
PNC
Timing of PNC visits
Day 1* 56 35 48
Day 3 47 55 50
Day 7 46 51 48
Day 42* 11 42 24
Components of counselling
Promote breastfeeding* 80 61 72
Vaccination 62 57 60
Keeping baby warm 56 45 52
Keeping cord clean 48 43 46
Refer to health post 37 29 34
Newborn danger signs* 34 18 28
Newborn danger signs
Signiicantly reduced or no feeding 100 100 100
Fever 79 72 76
Fast breathing 40 45 42
Convulsions 18 17 18
Signiicantly reduced or no movement 11 10 11
Chest in-drawing 7 10 8
Figure 16. WDA leaders’ knowledge (unprompted): correct timing of PNC home visits
0%
20%
40%
60%
80%
100%
Late implementers (n=100)Early implementers (n=140)
All neonatal visits (all four visits)Early neonatal visits (irst three visits)
% o
f WDA
lead
ers
27 26 2727
67 half had knowledge on the need to counsel on keeping the cord
clean, referring to a health post, educating on newborn danger
signs and vaccination.
With respect to knowledge on newborn danger signs, 100% of
WDA leaders said reduced or no feeding and 76% said fever.
The rest of the key danger signs were known by less than half
of the WDA leaders and the level of knowledge did not difer by implementation areas.
WDA leaders’ knowledge: understanding of the family health card
WDA leaders’ knowledge of the family health card which was in
circulation during the midline survey was also assessed (Figure
17). Since then, the Ministry of Health has issued a new family
health card printed containing the same images in colour,
however in this report we have presented the black and white
versions.
In this study 89% (n=214) of WDA leaders had used the family
health card in the past and the proportion was higher among
on the continuum of care, including those we deemed hard to
understand in the absence of the linked text. WDA leaders were
asked if they had ever used the family health card and those that
said ‘yes’ were asked to describe images shown as lash cards.
On pregnancy care, less than a third of WDA leaders recognised
images linked with birth preparedness components and oedema
in pregnant women. Only 36% of WDA leaders could describe
the image showing provision of iron tablets for pregnant women,
with the proportion being higher among early implementing area
HEWs (47% vs 18%, p<0.001). Less than half of the WDA leaders
recognised image depicting HIV testing for couples. The image
showing high temperature in pregnant women was recognised
by two-thirds of the WDA leaders.
On delivery care, over three-quarters of WDA leaders did not
know the image depicting the notiication of home deliveries to HEWs, although knowledge was higher among WDA leaders in
early implementing areas (34% vs 7%, p<0.001).
On images relating to immediate newborn care, 80% recognised
“ON IMAGES RELATING TO IMMEDIATE
NEWBORN CARE, 80% RECOGNISED WASHING
HANDS WITH SOAP BEFORE TOUCHING THE BABY
AND 48% IDENTIFIED BREASTFEEDING BABY AT
NIGHT TIME.”
early implementing areas (94% vs 83%, p<0.01). As stated in Box
2, the family health card is a behaviour change communication
job aid used by HEWs and WDA leaders to teach key MNCH
messages. The images in the family health card are meant to be
self-explanatory, allowing users to understand the key messages
regardless of their literacy status. We selected a range of images
washing hands with soap before touching baby and 48%
identiied breastfeeding baby at night time. In both cases WDA knowledge of these images was higher in early implementing
areas (86% vs 71%, p value 0.04 and 59% vs 30%, p<0.001
respectively).
68
Figure 17. WDA leaders’ knowledge: family health card (job aid)
PREGNANCY CARE
47%
Maternal care
18%
Early
implementers
(n=140)
Late
implementers
(n=100)
47% 33%
Iron tablets for
pregnant woman*
31% 15%
HIV testing
for couple*
Edema in pregnant
woman*
73% 57%High temperature in
pregnant woman
28% 30%Birth preparedness
34% 7%Notifying HEW of
home delivery*
86% 71%Washing hands
with soap*
59% 30%Breastfeeding baby
at night time*
42% 33%Neonatal illness sign:
Lethargic/unconscious
newborn
11% 5%Neonatal illness sign:
Newborn with
breathing problem
34% 36%Neonatal illness sign:
Umbilical puss/
infection
66% 40%Nutrition for
sick baby: more
breastfeeding*
72% 45%Infant being
given vitamin A*
73% 51%Certiicate of
child’s vaccination
completion*
IMMEDIATE NEWBORN CARE
Newborn care
DELIVERY CARE
Early
implementers
(n=140)
Late
implementers
(n=100)
NEONATAL CARE
INFANT CARE
* statistically signiicant
69 On newborn illness signs, 56% of WDA leaders were easily able to
recognise breastfeeding for a sick newborn and knowledge was
higher among early implementing WDA leaders (66% vs 40%,
p<0.001). Only 8% knew the image associated with a newborn
that has a breathing problem. Being lethargic/unconscious
and umbilical puss/infection was recognised by a third of WDA
leaders.
With respect to infant care, over 60% of WDA leaders were able
to describe images showing a child receiving vitamin A and the
certiicate of vaccination completion.
Overall, the vast majority of WDA leaders reported using the
family health card, which is a promising inding. A greater proportion of early implementing area WDA leaders had better
understanding of the majority of images used to assess their
knowledge, although overall more needs to be done to improve
all WDA leaders’ knowledge particularly in the area of newborn
illness.
PERFORMANCE IN THE LAST THREE MONTHS
In this section HEWs and WDA leaders were asked about the
MNH care-related services that they had provided in their
community in the three months preceding the date of the survey.
HEWs’ performance in the last three months
HEWs were asked about their performance in the last three
months (Table 22). Almost all (92%), HEWs said they had
provided ANC services during this time period. On average
HEWs had provided ANC to 25 women in the last three months.
Similarly, the majority of HEWs had provided PNC services for
mothers and newborns, (96% and 88%, respectively). On average
HEWs had provided PNC for 17 mothers and16 newborns.
Twenty-three percent of HEWs said they had identiied newborns with VSD and this was similar by implementation areas.
Treatment for VSD was provided by 17% of HEWs and 13% said
they had made a referral to a health centre. On average HEWs
had provided treatment to two newborns with VSD in the last
three months. Very few HEWs provided services for diarrhoea,
jaundice and pre-term or low birth weight babies.
WDA leaders’ performance in the last three months
The survey also assessed the level to which WDA leaders
provide services based on the orientation that is provided to
them by HEWs (Table 23). Over 80% had provided pregnancy
identiication and ANC counselling. There were also 20% of WDA leaders that reported having identiied pregnant women with danger signs. Over half (54%) of WDA leaders said they
had identiied women in labour and 79% had provided PNC counselling. About a third had identiied a sick newborn in the last three months. Compared with WDA leaders from late
implementing areas, a higher proportion of WDA leaders from
early implementing areas reported labour identiication (63% vs 41%, p=0.001), PNC counselling (85% vs 70%, p=0.01) and sick
newborn identiication (45% vs 18%, p<0.001). For each of these activities, on average WDA leaders provided services to two or
fewer individuals.
70Table 22. HEW performance: services delivered in the last three months
Table 23. WDA leaders’ performance: services delivered in the last three months
*p value <0.05for test of diference between early and late implementers
SEVICES PROVIDED EARLY
IMPLEMENTERS
LATE
IMPLEMENTERS
TOTAL
N=140 N=100 N=240
% % %
ANC 95 88 92
PNC for mother 96 95 96
PNC for newborn 88 87 88
PNC referral for newborn 9 16 12
Hypothermia: prevention 19 28 23
Hypothermia: management 1 2 2
Pre-term and/or low birth weight 3 7 5
VSD: identiication 21 27 23
VSD: treatment 17 16 17
VSD: referral 12 14 13
Diarrhoea 10 14 12
Jaundice 0 2 1
*p value <0.05for test of diference between early and late implementers
SERVICES PROVIDED EARLY
IMPLEMENTERS
LATE
IMPLEMENTERS
TOTAL
N=140 N=100 N=240
% % %
Pregnancy identiication 86 79 83
ANC counselling 89 80 85
Pregnancy danger signs identiication 18 22 20
Labour identiication* 63 41 54
PNC counselling* 85 70 79
Sick newborn identiication* 45 18 34
71
HEW showing new mother how to breastfeed
© Paolo Patruno Photography/IDEAS 2015
72
Under the case management section, we assessed HEWs
’competence in the management of CBNC-related young
infant newborn illnesses using three clinical vignettes.
HEWs’ ability to provide newborns with antibiotic injection
using a simulation model is presented under essential skill
assessment. Lastly, HEW consultation and independent re-
examination of young infants by health oicers is shared under case classiication.
CASE MANAGEMENT
HEWs’ competence to manage CBNC related young infant
illnesses was assessed using structured clinical vignettes.
The vignettes aimed to cover the key scenarios for an HEW
delivering CBNC. There were three vignettes: VSD case, VSD
follow-up care and general wellbeing of young infants. The
VSD case vignette had four domains (patient identiication, assessment, diagnosis treatment and advice/referral), while
the VSD follow up had two (treatment and advice/follow
up) and the general well-being vignette had three (patient
identiication, assessment, and advice/follow-up). HEWs were instructed to perform as per their routine, including
consulting their chart booklet or CBNC/iCCM register. Each
section of the vignette comprised of a narrative illustrating
a particular situation, which was read to the HEWs. After
each section HEWs were asked a question prompting
them to explain how, given the information provided, they
would care for the patient. Once the HEWs had provided a
response to the question, the following section was read to
the HEWs, containing information that the HEW may have
provided in answering the preceding section.
The following sections present the indings of HEWs’ skills and clinical reasoning with respect to management of VSD,
VSD follow-up care and general well-being of young infants.
6. MANAGEMENT OF YOUNG INFANT ILLNESS
CHAPTER SECTIONS
1. Case management
2. Essential skill assessment
3. Case classiication
73 VSD MANAGEMENT
After the opening narrative that introduced the scenario of a baby
girl with a cough, the HEW was asked what she would do. She
was then asked about her next steps after being informed that the
young infant is eight weeks old, has had the cough for ive days and that this is her irst consultation for the same illness. She was then asked about her actions after being informed that the baby
has no history of vomiting, but had a brief episode of convulsions
the previous day. Currently the baby has signiicantly reduced feeding and is lethargic. The HEW was then informed that the
young infants as chest in-drawing and a respiration count of 65
per minute and was asked what she will physically assess. After
being presented with inal set of signs and symptoms (cough for ive days, convulsion, breathing rate of 65/min, temperature of 39°C) the HEW was asked about her speciic immediate actions, followed by a question on any advice or referral she may provide
to the caregiver. Table 24 shows results from the clinical vignette
assessing HEWs’ competence in VSD management.
Patient identiication
Eighty-ive percent of HEWs said they would ask for baby’s full name and exact age, which was similar by implementation areas.
Asking about the duration of the cough was mentioned by 75%
of HEWs, but this was higher in early implementing area HEWs
(84% vs 64%, p=0.001). Very few HEWs in both early and late
implementing areas said they would ask if the visit was a irst visit or revisit.
Patient assessment
Over half of HEWs said they would ask the mother if the baby
has reduced feeding while less than half mentioned asking the
mother for history of convulsions. The majority (87%) of HEWs
said they would then count the babies breathing. However, less
than half said they would assess severe chest in-drawing. Only
48% said they would recount the breathing and 27% said they
would assess the infant’s movement when stimulated. Taking the
baby’s temperature was mentioned by 60% of HEWs.
Patient diagnosis and treatment
Once presented with inal set of signs, 88% said they would classify the young infant with a VSD, and providing a pre-referral
dose of gentamycin and amoxicillin was mentioned by around
three-quarters of HEWs.
Advice and referral
With respect to advice, 86% said breastfeed more frequently and
55% mentioned keeping baby warm, with a greater proportion
of HEWs from early implementing areas mentioning both
components of advice. Around 90% of HEWs mentioned that they
would advise mother on the need for referral and also refer to
the nearest health centre.
VSD FOLLOW-UP
The next scenario presented a young infant in need of a VSD
follow-up care. The HEW was told that she has been asked by
her HEW colleague to wait at the health post to provide follow-up
care for a young infant aged 5-6 weeks. The baby was diagnosed
with VSD by her HEW colleague while working in the community
the previous day. Her colleague has provided the baby with a
pre-referral dose of gentamycin and amoxicillin. As the family
was unable to go to the health centre, she also gave them
amoxicillin for home care and asked them to come to the health
post the next day for a gentamycin injection. The HEW was then
informed that the family has now come to the health post and
she was asked what steps she would take next, as her colleague
is out working in the community. The HEW was then told that the
baby’s age is six weeks and that her HEW colleague has given the
infant an intramuscular injection of gentamycin and the irst dose of amoxicillin. Her colleague has also told the family to give the
remaining amoxicillin twice a day for the next 6.5 days. The HEW
74Table 24. HEW skills of CBNC case management (clinical vignettes): VSD
*p value <0.05for test of diference between early and late implementers
EARLY
IMPLEMENTERS
LATE
IMPLEMENTERS
TOTAL
N=140 N=100 N=240
(%) (%) (%)
Correct patient identiicationFull name (baby) 84 88 85
Exact age (baby) 84 86 85
Exact duration of the cough* 84 64 75
First visit or revisit 17 13 15
If revisit, then medications history 4 3 3
Correct assessment
Ask
Stopped or signiicantly reduced feeding * 64 47 57
History of convulsions * 47 31 40
Examine
Physically observe the infant 53 55 54
Count the breathing 88 85 87
Severe chest in-drawing 53 40 48
Recount the breathing* 51 36 48
Measure temperature 62 56 60
Infant movement on stimulation 29 23 27
Correct classiication and treatmentClassify the neonate has a VSD 90 86 88
Give irst dose of amoxicillin 78 76 77
Give irst dose IM gentamycin 77 68 73
Correct advice and referral
Advice
Breastfeed more frequently* 92 78 86
Keep the infant warm* 61 47 55
Express breast milk if the child conscious
but unable to suck
49 38 44
Refer
Advice mother on the need of referral 89 85 87
Refer to the nearest health centre 90 92 91
75 was then asked about her next steps. The HEW was then told
that the baby is stable and the mother has given consent for the
injection. The HEW was then asked how she would prepare the
infant and herself for the injection. The HEW was then provided
with an injection model and asked to perform an injection, while
verbally describing the steps she was taking. Lastly, she was
asked about what steps she would take prior to the departure of
the family. HEWs’ responses to the VSD follow-up care vignettes
are shown in Table 25.
Patient treatment
Fifty-seven percent of HEWs said that they would ask for mother’s
consent to give the next injection. Over 70% said they would
ensure that the child is comfortable, select the site for injection
and prepare syringe as per prescription. With respect to hand
hygiene before injection, 52% said they would wash with soap
and water. Two-thirds of HEWs said they would use alcohol swab
over the injection site and 30% said they would allow the alcohol
to air dry. Over 80% identiied the correct anatomical injection point, stretched the skin and injected at the right angle. A greater
proportion of HEWs in early implementing areas performed all
three of these steps compared with HEWs from late implementing
area. Only 39% performed aspiration and 59% injected slowly,
while 62% applied a cotton ball at the injection site. Only a few
HEWs (19%) observed the injection site to check for discomfort,
swelling and pain. Over 90% then disposed the used syringe in
the appropriate container. With respect to hand hygiene after
injection, only 35% said they would wash with soap and water
and this was higher among HEWs from early implementing areas
(47% vs 17%, p<0.001). Another 8% and 6% said they would use
water and disinfectant, respectively.
Advice and follow-up
With respect to steps to take prior to the departure of the
family, over 80% said counsel on breastfeeding while a little
over 50% said counselling on sign and symptom monitoring and
temperature regulation. Almost all HEWs (92%) said they would
set up the time and date for the next follow-up visit.
GENERAL COUNSELLING FOR HEALTHY BABY
In this vignette, a HEW was asked about her actions once
informed that a boy is brought to the health post by his mother
for some advice on childcare and well-being. The HEW was
then asked what she would do after being told that the baby is
two weeks old and that it is his irst visit to a health post. She is then informed that the mother is interested in getting the “best
nutritional advice” for her young infant. After the HEW described
her next actions, she was told that the mother also wants to know
how she can prevent infections for her son. Lastly the HEW was
informed that the mother has received all the information she
needed and is very satisied. The HEW was then asked about her actions prior to the departure of the mother and newborn. HEWs’
responses are shown in Table 26.
Patient identiication
Similar to early scenarios, around 75% said they would get full
name and exact age of baby.
Photo: Injection model to assess HEW injection skills
© Limbs & Things
76Table 25. HEW skills of CBNC case management (clinical vignettes): VSD follow-up visit
*p value <0.05for test of diference between early and late implementers
EARLY
IMPLEMENTERS
LATE
IMPLEMENTERS
TOTAL
N=140 N=100 N=240
(%) (%) (%)
Correct treatment
Mother’s consent for infant’s injection 59 54 57
Ensure the child is comfortable* 79 64 73
Select site for injection* 87 64 78
Prepare syringe as per prescription 78 69 74
Hygiene before injection
Water only 7 13 10
Soap and water* 59 42 52
Disinfectant 14 9 12
Use alcohol swab 65 68 66
Allow the alcohol to air dry for 30 seconds 30 32 30
Intramuscular injection
Identiication of the correct anatomical injection point * 92 70 83
Stretch the skin* 84 73 80
Pierce the skin at an angle * 91 71 83
Perform aspiration 41 36 39
Slowly inject* 66 48 59
Apply cotton wool ball to the injection site 67 56 62
Following injection, observe site for at least 15 minutes,
checking for swelling, discomfort or pain
20 18 19
Dispose of sharps in appropriate container* 95 84 91
Hand hygiene after injection
Water only 6 10 8
Soap and water* 47 17 35
Disinfectant 6 5 6
Correct advice and follow-up
Advice
Breastfeeding 84 86 85
Sign and symptom monitoring 54 45 50
Temperature regulation 54 51 53
Follow-up
Set up next follow-up visit: time and date 93 90 92
77 Table 26. HEW skills of CBNC case management (clinical vignettes): general wellbeing of infant
including breastfeeding counselling
*p value <0.05 for test of diference between early and late implementers
EARLY
IMPLEMENTERS
LATE
IMPLEMENTERS
TOTAL
N=140 N=100 N=240
(%) (%) (%)
Correct patient identiicationFull name (Baby) 74 79 76
Exact age (baby) 76 82 78
Correct assessment
Check the immunisation status 66 65 66
Immunise child accordingly to status 70 61 66
Weigh the baby 39 52 44
Develop/update a family folder/card for the mother
and baby
13 24 18
Correct advice and follow up
Advice
Nutrition
Breastfeed as often as the child wants* 89 79 85
Breastfeed at day and night 10-12 times/day 91 90 91
Empty one breast irst before switching to the other 68 59 64
Exclusive breastfeeding for the irst 6 months 90 91 90
Don’t give other luids including water 89 91 90
Correct positioning for breastfeeding 79 82 80
Correct attachment of the baby 79 80 80
General
Wash hands with soap before and after touching the
newborn
72 61 68
Keep the baby warm* 76 62 70
Get the baby immunised on time 40 41 40
Follow-up
Give mother the date for the next follow-up visit 69 67 68
78Advice
Overall, HEWs’ knowledge on advice on nutrition was good.
The number and timing of breastfeeding as well as exclusive
breastfeeding without additional luids including water was mentioned by around 90% of HEWs, while 85% said to
breastfeed as often as the child wants. Eighty percent said they
would give advice on the correct positioning and attachment of
a baby. However, fewer HEWs (64%) mentioned emptying one
breast irst before switching to the other.
With respect to preventing infection, washing hands with soap
before and after touching the newborn was cited by 68% of
HEWs. With respect to general advice, 70% of HEWs said to keep
baby warm while less than half mentioned timely vaccination.
Advice and follow-up
Once informed of the mother’s satisfaction, checking
immunisation status and immunising child accordingly was
mentioned by 66% of HEWs. Only 44% said they would weigh
the baby and even fewer (18%) said they would develop/update
a family folder/card for the mother and newborn. Setting up a
follow-up visit was mentioned by 68% of HEWs.
In order to summarise the indings from clinical vignettes, the essential skills for management of each CBNC service scenario
for HEWs were assessed, summed up, converted into percentiles
and the mean diferences were compared between the two implementation groups (Figure 18a-c). Early implementing
area HEWs showed better clinical reasoning and skills for the
management of the VSD case and VSD case follow-up. HEWs
were similar with respect to clinical reasoning and skills for the
general counselling of a newborn.
Figure 18a-c HEWs: overall skill level of CBNC case management
0
20
40
60
80
100
Late implementers (n=100)Early implementers (n=140)
Mea
n sc
ore
(%)
56
415050
0
20
40
60
80
100
0
20
40
60
80
100
Mea
n sc
ore
(%)
Mea
n sc
ore
(%)
Figure 18a: VSD case
management
Figure 18b: VSD follow-up
visit management
Figure 18c: General
counselling
56
41
79 Table 27. HEW essential CBNC skill (clinical simulation): intramuscular injection of gentamycin
*p value <0.05 for test of diference between early and late implementers
EARLY
IMPLEMENTERS
LATE
IMPLEMENTERS
TOTAL
N=140 N=100 N=240
(%) (%) (%)
Care prior to injection
Hand hygiene
Water only 5 6 5
Water and soap* 49 30 41
Use of disinfectant* 16 7 12
Intramuscular antibiotic injection of neonate
Open the irst ampule successfully* 97 88 93
Fill up the syringe 1 ml* 95 81 89
Use alcohol swab 67 64 66
Allow the alcohol to air dry 39 33 37
Selection the correct injection site * 84 64 75
Stretch the skin* 87 52 73
Pierce the skin at an angle * 94 77 87
Perform aspiration * 53 38 47
Slowly inject 73 65 70
Care after injection
Apply cotton wool ball to the injection site 71 60 66
Appropriate disposal of the needles and syringe 96 97 96
Figure 19. HEW skills of CBNC case management (clinical simulation): overall skill level for
newborn injection management
*p value <0.05 for test of diference between early and late implementers
0
20
40
60
80
100
Late implementers
(n=100)
Early implementers
(n=140)
Mea
n sc
ore
38*
58*
80ESSENTIAL SKILL ASSESSMENT
To assess their injection skills, HEWs were provided with an
injection model for clinical demonstration. The injection model
was strapped on the left thigh of one of the data collectors
and the HEW was told assume the model was a thigh of a less
than one-month old newborn with all its lesh, blood and skin sensitivity. The HEW was informed that the newborn needed
gentamycin. They were then provided with all the materials
needed for the injection (alcohol, syringe, cotton swab and
gentamycin 20mg/2ml) and were asked to give an intramuscular
injection to the ‘newborn’s thigh’ (injection model). HEWs’
demonstrated skills on providing an intramuscular injection are
shown in Table 27.
Care prior to injection
With respect to hand hygiene, 41% washed with water
and soap, 12% used disinfectant and 5% washed with
only water. Hand hygiene practice was better among early
implementing area HEWs with respect to using water and soap
(49% vs 30%, p<0.01).
Intramuscular antibiotic-injection of neonate
Assessment of HEWs injection skills showed that 93% opened
the ampule successfully and 89% illed up the syringe to 1 ml, with HEWs in early implementing areas performing better
in both aspects. However, 33% did not wipe the injection site
with alcohol swab and 63% did not allow the alcohol to dry.
Around three-quarters of HEWs selected the correct injection
site and stretched the skin, again with a greater proportion of
HEWs in early implementing areas performing these actions.
Although 87% of HEWs pierced the skin at the right angle, only
47% performed aspiration to ensure there was no large blood
vessel at the injection site. Seventy percent of HEWs slowly
injected the model.
Care after injection
With respect to care provided after injecting the model, 66%
applied a cotton ball at the injection site. Almost all (96%)
appropriately disposed of the needles and syringes.
Similar to the clinical vignettes, the essential skills for
intramuscular injection were summed up, converted into
percentiles and mean diferences were compared between the two implementation groups (Figure 19). HEWs from early
implementing areas performed better than HEWs from late
implementing areas (mean diference of 20), although there is room for improvement for their overall skills.
“HAND HYGIENE
PRACTICE WAS
SIGNIFICANTLY
BETTER AMONG EARLY
IMPLEMENTING HEWS
WITH RESPECT TO
USING SOAP AND
WATER.”
81 Figure 20. Health post loor plan
4. Re-examination station 3. HEW’s assessment station
2. Observer station
1. Entry/exit interview station
Figure 21. HEW skills of CBNC case management: proportion of correctly classiied sick young infantsa
a Based on four key neonatal conditions: VSD, feeding problems/low weight, local bacterial infection
and jaundice.
0
20
40
60
80
100
Late implementers
(n=429)
Early implementers
(n=367)
% o
f HEW
s
3936
82CASE CLASSIFICATION
In this section we present the results of the sick newborn caregiver
entry–exit interview, observation of HEWs’ consultations of sick
young infant, and independent re-examination of the sick infant.
Figure 20 shows how the health post was set-up for this purpose.
The major challenge faced in conducing the case classiication, was the absence of caregivers spontaneously brining their sick
young infants to the health post for treatment. As a result, we
mobilised caregivers in the community to bringing their ‘sick
babies’ to the health post. An infant was included in this study if
he/she met the following criteria:
1. Was under the age of two months
2. Was considered sick by their caregivers
3. Was being seen for the irst time at the health post, or by either of the HEWs for the current illness episode
Caregivers were asked to respond to an entry interview that
ascertained background information about themselves and their
baby (Table 28). A total of 893 infants between the ages of 0-2
months were assessed, of which 505 were from early and 388
from late implementing areas. The majority of infants were 29
or more days old, with an average age of 35 days. Newborns in
the irst week of life made up only 3% of the study sample. Males comprised of 49% of the study sample and on average three
children less than two months were seen at each health post.
Background information on newborns
With respect to family characteristics, 98% of the individuals
accompanying the infants said they were the mothers and their
average age was 26 years. Only 39% were literate and a little over
half (57%) said they were employed. Almost all (97%) said they
were married. Women were asked about the newborn’s father
and 63% reported that the father was literate and 99% said the
father was employed. The average age of fathers was 33 years.
Experience of caregivers at health post
Table 29 shows the caregivers experience at the health post
(asked at the time of exit from the health post) and it shows that
overall they were content with the service that was provided to
them. They were asked if they faced any problems (minor and
major) at the health post with respect to waiting time, discussions
and explanations with HEWs, privacy, availability of medication,
working days and hours of the facility, and cleanness of the
facility. Having any major problems was reported by less than 5%
of families and 10% or less said they had any minor problems.
Table 30 shows the clinical diagnoses that were made by health
oicers upon re-examination of the babies. Feeding problems/low weight was common (73%) followed by local bacterial
infection (24%). Diagnosis of VSD was made in 16% of the infants.
The young infant illness clinical classiications comparing the diagnosis made by health oicers compared with those made by HEWs is shown in Table 31. Data collectors spent time with
HEWs the day before the sick young infant assessment to explain
the purpose and process of the study, ensuring that they were
comfortable and able to provide services as per their routine.
However, it is likely that HEWs performance might have been
diferent in the absence of the observer.
Overall, compared with the diagnosis made by health oicers, HEWs showed good speciicity (the ability to correctly identify an infant that does not have an illness as not having an illness).
Except for local bacterial infection and feeding problems/low
weight, 90% of HEWs correctly identiied those that did not have an illness. For local bacterial infection 19% of babies were
incorrectly diagnosed as having the condition, and 29% were
incorrectly diagnosed as having feeding problems.
Despite having good speciicity, HEWs skills in correctly identifying those with an illness as having an illness (sensitivity) was poor.
Compared with diagnosis made by health oicers, HEWs missed 70% of VSD cases and 72% of young infants with feeding
83 Table 28. Health post level: characteristics of study sample being assessed
a N=700 (29 did not have a husband and 164 did not know their husbands age) b N= 864 (29 were did not have a husband)
*p value <0.05 for test of diference between early and late implementers
EARLY
IMPLEMENTERS
LATE
IMPLEMENTERS
TOTAL
N=505 N=388 N=893
(%) (%) (%)
Child characteristics
Child age (days)
Early neonate (1-7 days) 3 3 3
Late neonate (8-28days 33 37 35
Young infant (29 -59 days) 63 61 62
Age (mean) 35 35 35
Child gender
Female 51 51 51
Male 49 49 49
Number of children observed per health post (mean) 2 3 3
Family characteristics
Mother’s (caregiver)
Age in years (mean) 26 26 26
Relationship with the child: biological mother 98 98 98
Literate 43 33 39
Employed 58 55 57
Married 97 96 97
Father’s characteristics
Age in years (mean) a 33 33 33
Literate b 67 57 63
Employed b 99 98 99
84Table 29. Health post level: experience of care seeking
*p value <0.05 for test of diference between early and late implementers
EARLY IMPLEMENTERS LATE IMPLEMENTERS TOTAL
N=505 N=388 N=893
(%) (%) (%)
Waiting time
Major problem 3 2 3
Minor problem 9 11 10
Opportunity to discuss problems
Major problem 1 0 <1
Minor problem 5 2 4
Explanation given by the HEW*
Major problem 1 0 <1
Minor problem 6 3 5
Privacy during consultation
Major problem
Minor problem 2 5 3
Availability of medicines*
Major problem 5 3 4
Minor problem 7 4 6
Working hours of the health facility
Major problem 2 1 2
Minor problem 6 4 5
Working days of the health facility
Major problem 1 3 2
Minor problem 5 7 6
Cleanliness of the facility *
Major problem 3 1 2
Minor problem 6 11 9
85
Table 30. Clinical case classiication using the iCCM chart booklet: young infant cases diagnosed by health oicers (re-examiners)
*p value <0.05for test of diference between early and late implementers
CASES DIAGNOSED
BY THE RE-EXAMINERS
EARLY
IMPLEMENTERS
LATE
IMPLEMENTERS
TOTAL
N=505 N=388 N=893
(%) (%) (%)
VSD 14 17 16
Feeding problems/low weight* 66 81 73
Local bacterial infection* 21 28 24
Jaundice 0 0 0
problem. Compared with the other illnesses, HEWs had better
sensitivity for local bacterial infection (55%).
The overall skill level of HEWs for correctly classifying a sick young
infant based on four key neonatal conditions (VSD, feeding
problems/low weight, local bacterial infection and jaundice) was
assessed and compared between early and late implementing
areas (Figure 21). Of the young infants diagnosed as having one
of the four conditions by health oicers, 37% were captured by HEWs. This was similar between implementation areas. This
shows that two out of ive sick newborns are identiied by HEWs.
Overall, the vignettes show that HEWs lack the skills to recognise
the symptoms and correctly diagnose a sick young infant.
However, once provided with the symptoms, they are able
to correctly classify and provide appropriate treatment. With
respect to their injection skills, there were also gaps, although
fewer gaps were seen among HEWs in early implementing areas.
The case management assessment showed that HEWs had the
ability to correctly classify young infants with no illness, but that
their competence to correctly diagnose young infants with an
illness, as having an illness, was low.
Table 31. Clinical case classiication using the iCCM chart booklet: comparability of neonatal cases diagnosed by health oicers (re-examiners) vs HEWs
CLASSIFICATION
EARLY IMPLEMENTERS LATE IMPLEMENTERS TOTAL
N=505 N=388 N=893
Sensitivity
(%)
Speciicity (%)
Sensitivity
(%)
Speciicity (%)
Sensitivity
(%)
Speciicity (%)
VSD 38 95 22 99 30 97
Feeding problems/low weight 30 78 25 53 28 71
Local bacterial infection 58 84 51 75 55 81
Jaundice - 97 - 93 - 95
86
The CBNC midline quality of care survey was done over the
course of six-and–a-half weeks, in 30 woredas. Of these, 18
were in CBNC early implementing woredas, where the CBNC
programme had been introduced and running for one year
and seven months. The remaining 12 woredas were in late
implementing areas, where CBNC had been introduced a
few months prior to the survey, giving HEWs insuicient time to put into practice skills required to provide key components
of the CBNC programme. A total of 117 PHUCs were visited
in this study (70 in early and 47 in late implementing areas),
240 health posts (140 in early and 100 in late implementing
areas), as well as HEWs and WDA leaders. Furthermore, 893
sick young infants (505 in early and 388 in late implementing
areas) were classiied clinically by HEWs and then re-examined by health oicers.
As mentioned in Chapter 1, early implementing (Phase I)
zones were selected by the Government of Ethiopia for having
a better health system performance. The start of CBNC Phase
II approximately a year after the start of Phase I was intended
to strengthen the health system of late implementing areas.
As such, early implementing areas might have performed
better than late implementing areas, irrespective of CBNC
programme implementation.
This section will provide a discussion on the four domains
through which the CBNC quality of care has been
conceptualised: A) health system readiness to provide
quality CBNC services; B) health system integration to provide
quality CBNC services; C) the potential of health workers
and volunteers to provide quality CBNC services; and, D)
management of young infant illness by HEWs.
7. DISCUSSION
This chapter will provide a discussion on
the four domains through which the CBNC
quality of care has been conceptualised.
87 HEALTH SYSTEM READINESS TO PROVIDE QUALITY
CBNC SERVICES
Facility readiness for CBNC services: infrastructure
Overall, there was a lack of water and cell phone signal at both
health posts and health centres. Strikingly, only around a half
of health centres had soap or hand sanitiser, with the igure dropping to less than a third among health posts. Furthermore,
a quarter of health posts and health centres were using a water
source that was deemed to be unsafe. These have implications
for hygiene at the facilities, including the hand washing practices
necessary when providing care for newborns.
Facility readiness for CBNC services: staf and operation hours
There were two or more HEWs present at 76% of health
posts. A smaller proportion of early implementing area health
posts had only one HEW available (18% vs 33%). Eighty-ive percent of health posts were open for ive days a week, with the remaining 15% being operational two to four days a week.
Insuicient numbers of HEWs and health post closures can undermine CBNC services, which would run more eiciently with a fully stafed health post that is operational on all working days of the week.
Facility readiness for CBNC services: equipment and supplies
Health centres in both early and late implementing areas were
well equipped and had suicient supplies to provide basic newborn care. However, a sizable number of health centres
lacked a newborn warmer and a nasogastric tube. The majority
of health posts in both early and late implementing areas had
most of the basic equipment for providing newborn care.
Facility readiness for CBNC services: job aids
The majority of both early and late implementing area health
posts and health centres had the necessary CBNC job aids such
as IMNCI/iCCM registers and chart booklets. The majority of
WDA leaders also reported having family health cards, with the
proportion being higher in early implementing areas.
There is room for improving the availability of supervision
checklists at health centres. At health post level, similar attention
is needed for HMIS forms. Furthermore, health posts also lacked
stock and bin cards, as well as request and resupply forms. To
ensure a suicient supply of drugs and minimise expiry, it is important to provide the necessary forms and trainings to HEWs.
Facility readiness for CBNC services: drugs
When looking speciically at drugs needed for the management of VSD at health centres, a majority have gentamycin (90%) and
amoxicillin (93%). Ampicillin was available in 68% of health
centres. Given that the standard protocol for CBNC treatment by
HEWs is to refer sick newborns to health centres, it is important
to ensure that all health centres have the necessary drugs to treat
VSD to ensure a functional referral system.
The availability of drugs at the health post level showed that 97%
of health posts had amoxicillin and 91% had gentamycin, with
84% of health posts having both drugs. A higher proportion of
late implementing area health posts had both drugs, which is
likely due to the fact that they were supplied with a year’s worth
of amoxicillin and gentamycin at the training they had received
around the time of the midline survey. The lower availability
of CBNC drugs in early implementing areas raises the issue of
sustainability of the CBNC momentum.
Availability of zinc and ORS for the treatment of diarrhoea at
health posts showed that only a quarter of facilities had both
and around a third had neither zinc nor ORS. There was a high
level of expiry for both zinc (51%) and ORS (23%) at health posts,
creating a false assurance. Supervisory visits to health posts need
to ensure that there is a set protocol for the timely removal and
replacement of expired drugs.
88Function of health facilities: supervision
This study showed a great gap in the level of supervision at the
PHCU level. A quarter of health centres had not provided an
integrated supportive supervisory visit to any health post in the
previous one month. For the same time period, less than half
of the health posts reported receiving a supervisory visit from
a health centre. This gap is striking, as it is recommended that
health posts receive about two visits per month.
Although the number of integrated supportive supervisory visits
was not suicient, when provided, visits covered a variety of themes. Yet, there was a gap in the supportive supervision for
newborn care. Less than half of HEWs reported that supervision
they had received in the last six months had covered support
for VSD management and this was similar among early and
late implementing areas. This has implications for the quality
of CBNC care that is provided by HEWs. Their technical skills on
CBNC related illnesses (signs, classiication and treatment) need to be reinforced through mentorship and supportive supervision,
as they are unlikely to frequently encounter suicient VSD cases to put into practice what they have been trained on through the
CBNC training.
CBNC focused group supervision in the form of PRCM meetings is
intended to be organised twice a year, the irst one taking place six months after CBNC training. There is a good indication that
this meeting is taking place with the desired frequency; three-
quarters of health centres had organised such a meeting in the
last six months and about two-thirds of HEWs reported attending
a meeting in the last six months. Organisation and attendance
of PRCM meetings was higher in early implementing areas. The
smaller proportion of PRCM meeting attendance among late
implementing HEWs is likely due to the fact that their CBNC
training had taken place less than six months before the survey.
In contrast with the regular integrated supportive supervision,
three-quarters of HEWs said that the PRCM meeting they had last
attended had covered VSD management.
Less than half of HEWs reported receiving a CBNC post-training
follow-up visit. Even among early implementers who had had
their initial training a year-and-a-half prior to the survey, only
half reported receiving such a visit. The CBNC post-training
follow-up visit is intended to ensure the initiation of services.
Such low levels of post-training follow-up can lead to HEWs not
providing CBNC services. However, the proportion reported in
this survey might underestimate the actual level of post-training
follow-up visit, if HEWs are not made aware that such a visit
is diferent from the regular integrated supportive supervisory visit.
The existence of major gaps in supervision is further illustrated
by levels of satisfaction with supervision HEWs had received,
with only half of HEWs saying that they were satisied. There was a strong demand from HEWs to increase the number of
supervisory visits and the recommendation to increase technical
(skills building) supervision.
Facility readiness for CBNC services: service utilisation for ANC, delivery
and PNC
Facility service records for the three months preceding the survey
(July-September 2015), showed that compared with the number
expected pregnancies, there were still gaps in service utilisation
for ANC; 28% of expected pregnancies at health centres and 50%
of expected pregnancies at health posts had not received ANC.
Facility delivery among women who had had at least one ANC at
a health centre was relatively high. This shows the importance of
ANC visits in promoting facility delivery. When assessing facility
deliveries against the number of expected pregnancies, the gap
in facility delivery rises to 35%. However, the observed gaps in
ANC and facility delivery could be due to high target setting and
poor record keeping.
With respect to PNC, the irst PNC care at the health centre was relatively high, and even higher when looking at how facilities
deine the irst visit. Among those that count PNC 1 as any care prior to discharge within the irst day of delivery, the proportion
89 receiving care is dramatically higher than among those that
deine PNC1 as care provided after discharge but within 24 hours of delivery. Problems of misclassiication and interpretation are likely to arise due to these varying deinitions of the PNC 1 in the ield. There is a major gap in all three PNC visits at the health post level, which indicates the decreased opportunities for identifying
newborns with illnesses.
The register review of the four ANC visits (ANC visit one = 1st
trimester, ANC visit two = 2nd trimester, ANC visit three and four
= early and late 3rd trimester) and four PNC visits (visit one = day
1, visit two = day 3, visit three = day 10 and visit four = day 42)
indicated that there is some potential for misclassifying ANC and
PNC visits during record keeping. It is likely that some HEWs and
health centre staf members are recording visits based on the timing of a visit, while others are recording visits based on the
number of visits, requiring caution in interpretation of these data.
Facility readiness for CBNC services: linkages
This study found good linkages between WDA leaders and
HEWs, with 86% reporting a meeting once or more in the last
month. HEWs and WDA leaders also reported that in addition
to meeting, they jointly carried out activities such as conducting
health campaigns, providing household visits and organising
pregnant women’s conferences. These strong linkages can
be further utilised to provide orientation for WDA leaders on
newborn danger signs, as well as sick newborn referrals and
reporting.
The organising of pregnant women’s conferences was relatively
high; 87% of HEWs reported that they had organised a conference
in the last three months. The majority of HEWs organised monthly
conferences. With respect to community attendance, over half of
HEWs reported that at the last pregnant women’s conference
all of the pregnant women in their catchment populations
had attended the meeting. A pregnant women’s conference
is an efective means for raising community awareness and mobilisation. Given the large proportion of HEWs and WDA
leaders organising conferences and high levels of attendance
among pregnant women, it is important to ensure PNC and sick
newborn care are consistently addressed.
WDA leaders also played an active role in engaging with
community members such as religious leaders, women’s savings
groups and the command post. However, in late implementing
areas, engagement of WDA leaders with religious leaders and
the command post was lower compared with early implementing
area leaders. In both areas WDA leaders’ engagement with
traditional birth attendants was minimal. Their engagement
with all key members of the community to raise awareness on
the importance of facility delivery, PNC and sick newborn care
is important to bring about an increase in the uptake of such
services.
Overall, there are aspects of the health system that indicate
readiness to provide quality CBNC services. The linkages between
health post, WDA leaders and communities were good. Most
facilities have the necessary equipment to provide CBNC services,
as well as suicient supplies and job aids. Yet, some facilities had stock-outs of key CBNC-related drugs. The most notable gap in
health system readiness was in supervision, both in frequency
and content with respect to newborn care.
HEALTH SYSTEM INTEGRATION WITHIN THE PHCU
FOR QUALITY CBNC SERVICE
Supply chain: drugs
Amoxicillin (125 mg dispersible tablets, 250 mg dispersible
tablet and 125mg/5ml syrup) availability at health centres for
supplying health posts was high, with only 2% reporting stock-out
lasting three months or more. In contrast, 43% of health centres
reported gentamycin stock-out lasting at least three months.
The high level of gentamycin stock-out could be because health
centres are encouraged to pass on these drugs to health posts,
rather than retaining them in their own storage.
90Direct supply of gentamycin for health centres was mainly from
the woreda health oices, followed by implementing partners. The majority of early implementing areas were supplied by
implementing partners and the majority of late implementing
areas were supplied directly by woreda health oices. For the CBNC programme to be sustainable with respect to drugs, it will
be important to select the most eicient system and source for the supply of drugs, with implementing partners playing less of a
central role in this regard.
Referral: forms
The use of referrals forms is a key part of the CBNC programme,
but less than half of health centres reported getting referral forms
from health posts. However, a higher proportion of facilities in
early implementing areas reported that HEWs in their catchment
population did send referral forms.
Referral: register review
Low level of service utilisation for sick young infants was apparent
in some PHCUs. Register reviews showed that 11% of IMNCI
registers at health centres and 19% of iCCM registers at health
posts had not recorded any 0-2 month old sick infants in the three
months preceding the survey. Furthermore, among the 13% of
sick young infants referred from health posts to health centres,
very few (7%) could be cross-linked between the 0-2 months
iCCM register at a health post and the 0-2 month IMNCI register
at the referral health centre. The problem was further highlighted
by the large proportion of health posts and health centres that
had recorded a young infant health outcome as ’unknown’. Lack
of follow-up on referrals has negative implications on the health
outcome of a sick young infants. Furthermore, the possibility of
drug resistance increases among those who receive a pre-referral
dose of antibiotics with no follow-up care.
Referral: ambulance
Over half of health facilities reported that during the last
obstetric referral from the health post to the health centre
government-owned transport was used. Although this
proportion is promising, more efort is needed to improve the availability of free transport through government-owned
vehicles both for pregnant women and sick young infants.
This could increase the above mentioned level of follow-up
on referrals from health post to health centre, which is
currently low.
Overall, health centres had stock-outs of gentamycin (20mg/2ml)
lasting three months, indicating a potential problem in their
capacity to replenish health posts. With respect to the referral
system, the most notable gap is the lack of follow-up of sick
newborn referrals from health post to health centre. In addition,
the majority of health centres reported not receiving referral
forms. Improving the availability of free government transport for
sick newborns can also increase the follow-up rate from health
post to health centre.
POTENTIAL OF HEALTH WORKFORCE TO DELIVER
QUALITY CBNC SERVICES
Training: health centre staf
An IMNCI trained staf member was available in 95% of health centres and on average there were two trained individuals per
facility. CBNC trained staf members were available in 68% of health centres and this was similar across implementation
areas. Approximately one-ifth of IMNCI and CBNC trained PHCU staf were reported to have left, with minimal replacement by trained staf. The high availability of IMNC trained staf at health centres is promising. The quality of CBNC supportive supervision
and mentorship for HEWs can be enhanced by improving the
availability of health centre staf trained in both CBNC and IMNCI.
91 Training: HEWs
Almost all HEWs had received CBNC (98%) and iCCM (99%)
trainings. However, a quarter of HEWs reported not attending an
annual integrated refresher training in the last 12 months. HEWs’
satisfaction with training was much better than their satisfaction
with supervision; around 66% of HEWs reported being fully
satisied, with satisfaction being higher among HEWs in early implementing areas. The majority mentioned that their training
would be improved by post-training supervision, followed by
practice sessions and training aids.
Training: WDA leaders
Training for WDA leaders across the continuum of care was
impressively high in both early and late implementing areas and
the majority were satisied with their orientation. However, a
higher proportion of WDA leaders in early implementing areas
were more satisied with the training they had received. Yet, despite the received training, WDA leaders’ knowledge on some
aspects of MNH care was lacking (discussed below).
HEW unprompted knowledge: PNC, newborn illness and treatment
Overall, HEWs had good knowledge on breastfeeding counselling
during PNC visits. The major gap is checking newborn danger
signs during all PNC visits, which a third of HEWs did not mention.
Furthermore, knowledge on cord care and keeping baby warm
were sub-optimal.
With respect to newborn illness, HEWs did not have suicient unprompted knowledge on VSD signs; less than two-thirds of
HEWs mentioned the majority of signs. Knowledge of signs for
local bacterial infection and severe jaundice were also lacking,
Figure 22. The four domains used to conceptualise the quality of CBNC services.
MANAGEMENT OF YOUNG INFANT ILLNESS
HEALTH SYSTEM INTEGRATIONHEALTH SYSTEM READINESS
CBNC QUALITY OF CARE
POTENTIAL OF HEALTH WORKERS AND VOLUNTEERS
92particularly for HEWs from late implementing areas. HEWs are not
expected to memorise danger signs, rather they are instructed to
follow the chart booklet when assessing, classifying and treating
newborns. However, they need to know the key danger signs that
should prompt them to refer to the chart booklet.
For treatment, there were gaps in HEWs’ knowledge on providing
a pre-referral dose of antibiotics for VSD, as well as knowledge
on treating local bacterial infection with amoxicillin.
Zinc and ORS for the treatment of moderate dehydration was
known by almost all HEWs and the need to refer urgently for
severe illnesses was acknowledged by most. The minimal gap
in HEW knowledge on the treatment of moderate dehydration
indicates that with the proper training, mentorship, support
and practice, HEWs can also improve their knowledge on the
management of VSD. Ensuring that HEWs attend Integrated
Refresher Training, PRCM meetings and other training and
mentorship opportunities that can further reinforce their
knowledge on the treatment algorithms for CBNC illnesses is key
for ensuring the quality of services that HEWs are able to provide.
Knowledge: WDA leaders
Although training for WDA leaders across the continuum of care
was good, their actual knowledge varied across thematic areas.
There was a gap in knowledge on the exact timing of PNC visits,
with less than15% of WDA leaders stating the exact days of visits
in the irst week and even fewer (4%) still knowing the exact days of all the four PNC visits.
There was an even a greater gap in knowledge on newborn
danger signs, with knowledge among early implementing
area WDA leaders being better than WDA leaders from late
implementing areas. The majority of newborn danger signs were
known by less than 50% of WDA leaders.
The survey used novel techniques to assess WDA leaders’
knowledge on the family health card, which is a key behaviour
changing communication job aid used by WDA leaders to teach
key MNCH messages. Although WDA leaders’ understanding of
the key newborn danger signs (lethargy, breathing problem and
infected umbilical cord) conveyed by the family health card images
were sub-optimal, overall, leaders from early implementing
areas had better knowledge. This is perhaps due to the larger
proportion of WDA leaders from early implementing areas who
reported receiving training on using the family health card. WDA
leaders’ lack of knowledge on PNC timing and newborn danger
signs indicates that there is a strong need to improve the quality
of the orientation that is provided to them by HEWs.
Performance: HEW
HEWs’ assessment of performance with respect to service delivery
on ANC as well as maternal and newborn PNC in the three months
preceding the survey was relatively high. However, only a quarter
of HEWs reported having provided care for newborns with VSD.
This indicates that HEWs are likely missing some cases of VSD in
the community. More mentorship and supervision is necessary
to ensure that HEWs and WDA leaders are creating demand for
sick newborn services provided by the CBNC programme.
WDA leaders’ performance
Given the expected number of pregnancies and deliveries in a
given WDA network, the majority of WDA leaders had provided
some pregnancy identiication, ANC and PNC counselling. A third of WDA leaders said they had identiied a newborn with an illness in the last three months. Overall, WDA leaders in early
implementing areas performed better than WDA leaders in late
implementing areas. This indicates that with the appropriate
support from HEWs, the function of the WDA network can be
improved.
Overall, HEWs and WDA leaders had some strengths as well
as weaknesses. Almost all HEWs in this study were trained
in CBNC, indicating a good momentum in the scale up of the
CBNC programme throughout the country. HEWs’ unprompted
93 knowledge of VSD signs needs improvement. However, it is also
important to note that, as per government guidelines, HEWs
are not expected to memorise all danger signs, but rather to
follow and adhere to the iCCM chart booklet. Although there
were IMNCI trained staf members at health centres, there was a shortage of CBNC trained staf. This has implications for the support that can be provided by health centres to HEWs. WDA
leaders’ training across the continuum of care in the last year was
high, although the quality of orientation that is provided to them
needs to be improved. WDA leaders did not know key aspects
of PNC (timely visits), or newborn danger signs. They also had
limited knowledge of some of the images used in the family
health card.
MANAGEMENT OF YOUNG INFANT ILLNESS
HEWs’ skills on CBNC case management: clinical vignettes
HEWs’ clinical skills and understanding for VSD case
management, VSD follow-up care and general counselling for a
healthy newborn was assessed using clinical vignettes. Overall,
their patient identiication was good, although not fully optimal. This is similar to indings from the 0-2 months iCCM and IMNCI register reviews, which showed near complete data on young
infant’s age, gender, name and address. However, many HEWs
did not ask if the visit was a irst or second visit, nor did they check the infant’s medication history. These omissions have
implications for the CBNC programme, particularly for VSD, as
the management protocol is diferent for irst and follow-up visits. Furthermore, not assessing prior medications for VSD
inluences drug resistance, compliance and reaction problems.
HEWs were not competent in identifying the necessary signs to
correctly diagnose a sick young infant. Again, this was similar
to indings from the iCCM register reviews. However, once they were informed with the correct signs, the majority were able
to provide the appropriate diagnosis and treatment. This was
similar for both early and late implementing areas.
Overall, HEWs in both early and late implementing areas were
similar with respect to their clinical skills to provide counselling
for a healthy newborn. HEWs from early implementing areas had
relatively better clinical reasoning and skills for the management
of VSD cases. Lack of HEW competence in recognising symptoms
for speciic diseases highlights an area for focused training, which can bridge the observed gap.
HEW essential skill assessment: intramuscular injection of gentamycin
Assessment of HEWs’ skills in providing an intramuscular injection
of gentamycin to a neonate showed that their overall skill is low,
which was surprising as HEWs do have experience of giving
vaccinations. However, more HEWs from early implementing
areas demonstrated better injection skills than those from late
implementing areas.
94Clinical case classiication: young infant illness
As mentioned earlier in the discussion, this study conducted
young infant illness case classiication for 893 babies that were considered sick by their caregivers. Although the WHO health
facility assessment guide does not include case observation for
0-2 month infants, we adapted the tools used for 2-59 month old
children in accordance with the iCCM chart booklet issued by the
Ethiopian Ministry of Health. The survey observed HEWs skills to
correctly diagnose a sick young infant as per their CBNC training.
Data collectors spent time with HEWs the day before the sick
young infant assessment to explain the purpose and process
of the study, ensuring that they were comfortable and able to
provide services as per their routine. However, it is likely that
HEWs performance might have been diferent in the absence of the observer.
Cases diagnosed by health oicers showed that the young infants presented with a range of illnesses, including VSD, local bacterial
infection and feeding problems. When comparing the health
oicers’ diagnoses using the iCCM chart booklet with those made by HEWs, it was apparent that HEWs were able to correctly
identify infants that did not have a particular illness as not having
an illness, which is commendable, as it could potentially lead to
less misuse of antibiotics for infant illness by HEWs. However,
HEWs’ skill to correctly identify infants with an illness as having
an illness leaves room for improvement. HEWs had correctly
diagnosed two out of ive sick infants between the ages of 0-2 months. This indicates that some young infants who were actually
sick were not receiving the appropriate life-saving drugs at the
health post level.
It is important to note that there are several factors afecting HEWs’ ability to correctly diagnose a sick young infant, including
opportunities to practice clinical skills, supportive supervision
and clinical mentoring. This was not assessed for in this report.
Such a nuanced review will be part of future analysis.
Clinical case classiication: maternal satisfaction
The experience of caregivers at health posts was very positive.
Exit-interviews showed that they were satisied with the care that was provided to them by the HEWs.
With respect to management of young infant illness, it is evident
that HEWs lack skills to recognise danger signs. However, once
the danger signs are known, they are competent in correctly
diagnosing infants and providing appropriate care. Despite
providing injections for vaccinations, the assessment of HEWs’
administration of intramuscular injections of gentamycin
indicated that they needed further training. Despite these
shortcomings, HEWs provided services to caregivers that left
them satisied by the experience, which could potentially endorse positive health seeking behaviour by the community for neonatal
illness and create community demand for CBNC services.
95
RECOMMENDATIONS
This survey provides an overview of the
quality of CBNC services provided in early
and late CBNC implementation areas.
Below we provide recommendations for
the overall improvement of the quality
of the CBNC programme. However, it is
strongly recommended that the results
presented in chapters 3-6 are thoroughly
reviewed to identify overall gaps in quality,
as well as gaps speciic to early and late
implementation areas. Based on the indings
from this midline survey, we present
the following key recommendations for
improvement across the four domains used
to conceptualise quality
CBNC service delivery:
HEALTH SYSTEM READINESS TO PROVIDE
QUALITY CBNC SERVICES
1. Incorporate supportive supervision activities speciic to CBNC and iCCM into routine supervision visits
2. Make provision of MNCH/CBNC related integrated
supportive supervision for HEWs as a key responsibility
of health centre staf, by including it as an indicator during their performance review
3. Increase the frequency of supervision from health
centres to health posts, ensuring that visits cover an
assessment of HEWs’ VSD service provision as well
monitoring drug supply and expiration dates
4. Improve the infrastructure, especially the water supply
5. Develop and implement a well-deined matrix for measurement of ANC and PNC through HMIS
6. Explore the possibility of integrating post-natal care
services with CBNC practices, as they are targeting the
same timeframe and closely linking them will beneit both services
HEALTH SYSTEM INTEGRATION WITHIN THE
PHCU FOR QUALITY CBNC SERVICES
1. Improve the supply chain system for CBNC related
drugs, ensuring that the drugs are fully incorporated
into the Pharmaceuticals Fund and Supply Agency and
Integrated Pharmaceutical Logistics System (IPLS)
2. To ensure follow-up on referrals from the health post,
increase access to woreda ambulances for transport of
sick young infants to health centres
3. Ensure the availability of oicial referral forms at health posts and train HEWs to use them when referring sick
newborns
4. Provide each sick young infant with a unique identiier for easy follow-up within the PHCU to ensure provision
and completion of treatment
96
POTENTIAL OF HEALTH WORKFORCE TO DELIVER
QUALITY CBNC SERVICE
1. Explore the possibility of including CBNC as part of pre-
service training to be supported by systematic on the job
mentoring
2. Ensure periodic and structured coaching by HEWs to
enhance WDA leaders’ understanding of MNCH promotion
messages spanning all CBNC components
3. Strengthen WDA leaders’ capacity for demand creation to
increase uptake of newborn services, focusing on their ability
to recognise danger signs for young child illness and efective use of the family health card.
4. HEWs and WDA leaders’ trainings should incorporate their
satisfaction and engagement to inform the content and
design of future trainings
MANAGEMENT OF YOUNG INFANT ILLNESS
1. Create innovative, skills based training and mentoring
activities for HEWs focusing on the recognition of danger
signs in young infants
2. Provide periodic refresher training to HEWs on intramuscular
injections for young infants using innovative technologies
and methods
3. To overcome limited case load of sick young infants at the
health post level, invite HEWs periodically to health centres
to observe case management skills practiced by health
oicers4. Revitalise the skills labs, especially for HEWs’ CBNC
refresher trainings.
97
HEW showing new mother how to breastfeed
© Paolo Patruno Photography/IDEAS 2015
A1
APPENDICES
A2 APPENDIX I
POWER EARLY
IMPLEMENTERS
LATE
IMPLEMENTERS
ICC DESIGN
EFFECT
CONTROL INTERVENTION DIFFERENCE
Clusters no./size Clusters no./size
Case 1
0.632 70/2 50/2 0 1 40% 55% 15%
0.800 70/3 50/3 0.01 1.01 40% 55% 15%
0.800 70/4 50/4 0.12 1.35 40% 55% 15%
0.800 70/5 50/5 0.17 1.69 40% 55% 15%
0.800 70/6 50/6 0.21 2.03 40% 55% 15%
0.799 70/7 50/7 0.23 2.37 40% 55% 15%
0.799 70/8 50/8 0.24 2.71 40% 55% 15%
0.799 70/9 50/9 0.26 3.04 40% 55% 15%
0.800 70/10 50/10 0.26 3.38 40% 55% 15%
Case 2
0.799 140/2 100/2 0.35 1.35 40% 55% 15%
0.799 140/3 100/3 0.51 2.03 40% 55% 15%
0.800 140/4 100/4 0.57 2.71 40% 55% 15%
0.800 140/5 100/5 0.6 3.38 40% 55% 15%
0.799 140/6 100/6 0.61 4.06 40% 55% 15%
0.799 140/7 100/7 0.62 4.73 40% 55% 15%
0.799 140/8 100/8 0.63 5.41 40% 55% 15%
0.799 140/9 100/9 0.64 6.09 40% 55% 15%
0.799 140/10 100/10 0.64 6.76 40% 55% 15%
Case 3
0.807 210/2 150/2 1 3 40% 55% 15%
0.807 210/3 150/3 1 3 40% 55% 15%
0.807 210/4 150/4 1 4 40% 55% 15%
0.807 210/5 150/5 1 5 40% 55% 15%
0.807 210/6 150/6 1 6 40% 55% 15%
0.807 210/7 150/7 1 7 40% 55% 15%
0.807 210/8 150/8 1 8 40% 55% 15%
0.807 210/9 150/9 1 9 40% 55% 15%
0.807 210/10 150/10 1 10 40% 55% 15%
A3APPENDIX II
A. Health system readiness for CBNC services
Characteristics of population being served by PHCUs providing CBNC services
TRADITIONAL PRACTICES
EARLY
IMPLEMENTERS
LATE
IMPLEMENTERS
TOTAL
N=140 N=100 N=240
% % %
Avoidance of outside physical contact for newborn* 46 64 54
Avoidance of any visitors for the newborn 8 10 9
Avoidance of human contact for the newborn except mothers* 16 5 11
a Reported by WDA leaders
*p<0.05 for test of diference between early and late implementers
a Reported by WDA leaders b Early implementers n=65, Late implementers n=64 c Early implementers n=11, Late implementers n=10 d Early implementers n=22, Late implementers n=5
*p<0.05 for test of diference between early and late implementers
Figure 1. Neonatal cultural practices and traditions: days of avoiding physical and human contact a
0
20
40
60
80
100
Avoidance of human contact for the
newborn except for mothers*d
Avoidance of any
visitors for newbornc
Avoidance of outside
physical contact for newborn*b
Mea
n no
. of d
ays
2115 17
24 20
90
Table 1. Neonatal cultural practices and traditions: types of avoiding physical and human contact a
A4 Figure 2. PHCU and health post: characteristics of catchment population
*p<0.05 for test of diference between early and late implementers
01000 2000 3000 4000 5000 6000
Late implementers (n=47)
Early implementers (n=70)
Mea
n nu
mbe
r of
unde
r ive
child
ren
Mea
n nu
mbe
r of w
omen
of re
prod
uctiv
e age
Mea
n num
ber o
f hou
seho
lds
23947
24885 4462
5485
0 1000 2000 3000 4000 5000 6000
Late implementers (n=100)
Early implementers (n=140)
PHCU Health post*
0 6000 12000 18000 24000 30000
Mea
n nu
mbe
r of p
eopl
e
0 6000 12000 18000 24000 30000
5046
5292
5426
5460
3643
3635
808
630
1228
917
1125
928
A5Figure 3. PHCU and health post: characteristics of families residing in the catchment ares
Figure 4. WDA: Characteristics of families residing in the catchment areas
0 1 2 3 4 5 6
Late implementers (n=47)
Early implementers (n=70)
Mea
n num
ber o
f und
er iv
e ch
ildre
n/ho
useh
old
Mea
n nu
mbe
r of w
omen
of
repr
oduc
tive a
ge/h
ouse
hold
Mea
n nu
mbe
r of
peop
le/h
ouse
hold
0 1 2 3 4 5 6
Late implementers (n=100)
Early implementers (n=140)
4.7
4.7
1.1
1.0
0.7
0.7
0.7
0.7
1.1
1.0
4.9
4.8
31 302725
0
10
20
30
40
50
Late
impl
emen
ters
(n=4
7)
Early
impl
emen
ters
(n
=70)
Mea
n nu
mbe
r of
hous
ehol
ds
0
10
20
30
40
50
Late
impl
emen
ters
(n=1
00)
Early
impl
emen
ters
(n=1
40)
Mea
n nu
mbe
r of w
omen
of
repr
oduc
tive
age
A6 Facility infrastructure
Table 2. Health centre and health post: observation of infrastructure
*p value <0.05 for test of diference between early and late implementers
Table 3. Health centre: observed availability of newborn health related equipment and supplies
*p value <0.05 for test of diference between early and late implementers
EARLY
IMPLEMENTERS
LATE
IMPLEMENTERS
TOTAL
(%) (%) (%)
Health centre facility description n=70 n=47 N=117
Electricity supply* 73 89 80
Cell phone signal 79 68 74
Health post facility description n=140 n=100 N=240
Electricity supply 17 13 15
Cell phone signal* 65 77 72
EARLY
IMPLEMENTERS
LATE
IMPLEMENTERS
TOTAL
N=70
(%)
N=47
(%)
N=117
(%)
Equipment
Blood pressure cuf 97 94 96
Examination couch 100 100 100
Privacy curtain 87 79 84
Washable mackintosh 60 75 66
Dustbin 86 85 86
Supplies
Chlorine bleach* 97 79 90
Bucket for decontamination solution 87 83 86
Contaminated waste container 90 81 86
Pregnancy test kit 80 89 84
Proteinuria test kit 50 66 56
HIV test kit KHB 89 94 91
HIV test kit Statpak* 64 83 72
HIV test kit Unigold* 37 66 49
Syphilis RPR/VDRA test kit* 24 45 33
Syphilis rapid test kit* 21 49 33
Anaemia test kit 36 53 43
Blood glucose test kit 16 21 18
A7
Table 5. Health centre: observed availability of newborn health related drugs
*p value <0.05 for test of diference between early and late implementers
Table 4. Health post: observed availability of newborn health related equipment and supplies
*p value <0.05 for test of diference between early and late implementers
EARLY
IMPLEMENTERS
LATE
IMPLEMENTERS
TOTAL
N=140 N=100 N=240
(%) (%) (%)
Equipment
Blood pressure cuf 63 65 64
Examination couch 82 74 79
Privacy curtain 31 33 32
Washable mackintosh 32 27 30
Dustbin* 46 60 52
Supplies
Chlorine bleach 19 23 21
Bucket for decontamination solution* 38 20 30
Contaminated waste container 44 37 41
Cups for drinking water 76 77 76
DRUGS
EARLY
IMPLEMENTERS
LATE
IMPLEMENTERS
TOTAL
N=70 N=47 N=117
(%) (%) (%)
Antihelminths 91 79 86
Uterotonics* 21 64 39
Magnesium sulphate 37 40 39
Antibiotics for premature rupture
of membrane
66 60 63
A8 Table 6. Health post: observed availability of newborn health related drugs
EARLY
IMPLEMENTERS
LATE
IMPLEMENTERS
TOTAL
N=140 N=100 N=240
(%) (%) (%)
Malaria
Test kit for malaria*
Available 78 70 75
Not available 2 1 2
Expired 0 6 3
Never in stock 20 23 21
Duration of non-availability (mean days) * 31 92 74
Study area endemic for malaria 71 68 70
Among area where malaria is endemic
Coartem*
Available 79 62 72
Not Available 13 21 16
Expired 8 13 10
Never in stock 0 4 2
Duration of non-availability (mean days) 53 62 58
Chloroquine syrup
Available 28 19 24
Not Available 21 27 23
Expired 17 12 15
Never in stock 34 43 38
Duration of non-availability (mean days) 139 141 140
Artesunate suppository
Available 22 10 17
Not Available 3 6 4
Expired 6 7 7
Never in stock 69 77 72
Duration of non-availability (mean days) 140 108 12
A9
*p value <0.05for test of diference between early and late implementers
Newborn care and vaccinations
Vitamin K
Available 0 1 <1
Not available 1 0 <1
Expired -- -- --
Never in stock 99 99 99
TTC*
Available 46 43 45
Not available 43 25 35
Expired 1 2 2
Never in stock 9 30 18
Duration of non-availability (mean days) 90 53 79
Paracetamol
Available 66 63 65
Not available 11 14 13
Expired 11 7 7
Never in stock 11 16 13
Duration of non-availability (mean days) 94 65 82
BCG
Available 34 33 33
Not available 51 54 53
Expired -- -- --
Never in stock 15 13 14
Duration of non-availability (mean days) 24 26 25
Polio vaccine
Available 34 33 34
Not available 51 54 52
Expired -- -- --
Never in stock 15 13 14
Duration of non-availability (mean days) 24 23 24
Table 6. Health post: observed availability of newborn health related drugs, continued
A10 Function of PHCUs for CBNC related services
Table 7. Linkage of health centre and health post with community: activities in the last three months
a Due to the nominal nature of the variable categories, a Kendall’s Tau test was used to assess the signiicant statistical diferences
*p<0.05 for test of diference between early and late implementers
EARLY
IMPLEMENTERS
LATE
IMPLEMENTERS
TOTAL
N=70 (%) N=47 (%) N=117 (%)
A. By health centre
Participation in pregnant women’s conference*a
None 1 2 2
Every two weeks 27 2 17
Once a month 70 92 79
Every other month 1 4 3
B. By Health post
Organisation of pregnant women’s conference*a
None 12 15 13
Every two weeks 24 1 15
Once a month 56 81 66
Every other month 4 2 3
Every three months 4 1 3
Attendance of pregnant women during the last
conference*
64 50 59
C. By community member (WDA leader)
Meeting with HEW*
None 6 25 14
Once 12 14 13
More than once 82 61 73
Activities undertaken with HEWs
Plan together 66 71 68
Organise pregnant women’s conference 81 78 80
Provide household visits 89 81 86
Conduct health campaigns* 88 72 81
Organisation of pregnant women’s conference*a
None 8 33 18
Every two weeks 19 10 15
Once a month 70 48 61
Every three months 3 9 5
Attendance of pregnant women during
the last conference
86 83 85
A11Table 8. Supportive supervision: visits to health posts during the last six and three months
*p value <0.05 for test of diference between early and late implementers
SUPERVISION EARLY
IMPLEMENTERS
LATE
IMPLEMENTERS
TOTAL
N=70 N=47 N=117
(%) (%) (%)
Health posts visited in the last 6 months 98 99 98
Number visited (mean)* 5 4 5
Health posts visited in the last 3 months 91 90 90
Number visited (mean)* 5 4 4
B. Health system integration within the PHCU for quality CBNC services
Table 9A. Health centre IMNCI and Health post iCCM register review: PHCU level data records of
sick young infants, for health centres that did not have any sick infants registered in the previous
three months
WOREDA
AND PHCU
NAME
TOTAL NUMBER
OF INFANTS SEEN
IN THE HEALTH
CENTRE WITHIN
THE PHCU
TOTAL NUMBER OF INFANTS SEEN
IN THE SAMPLED SATELLITE HEALTH
POSTS
AVERAGE NUMBER OF INFANTS
SEEN AT THE FUNCTIONALa
SAMPLE
1 2 3 4
HEALTH
CENTRES OF
THE WOREDA
HEALTH
POSTS OF THE
WOREDA
Intervention
W19 P2 0 18 -- -- -- 3 8
W19 P5 0 1 -- -- -- 3 8
W19 P6 0 3 1 -- -- 3 8
W20 P1 0 2 0 1b 2
W23 P4 0 2 1 -- -- 15 1
Comparison
W15 P2 0 1 0 -- -- 18 b 2
W15 P3 0 2 0 -- -- 18 b 2
W15 P4 0 3 0 -- -- 18 b 2
W16 P2 0 7 2 -- -- 35 b 4
W16 P3 0 0 0 -- -- 35 b 4
W16 P4 0 3 -- -- -- 35 b 4
W18 P2 0 0 0 -- -- 2 3
W18 P3 0 4 0 -- -- 2 3
a Among health centres and health posts that had seen sick young infants in the last three months b Only one functional health centre sampled
A12 Table 9B. Health centre IMNCI and Health post iCCM register review: PHCU level data records of sick
young infants, for health postsa that did not have any sick infants registered in the previous three
months.
WOREDA
AND PHCU
NAME
TOTAL NUMBER OF INFANTS SEEN
IN THE HEATH POSTS WITHIN A
PHCU
TOTAL NUMBER
OF INFANTS SEEN
IN THE SATELLITE
HEALTH CENTRE
AVERAGE NUMBER OF INFANTS
SEEN AT THE FUNCTIONALb
SAMPLE
1 2 3 4
HEALTH
CENTRES OF
THE WOREDA
HEALTH
POSTS OF THE
WOREDA
Intervention
W10 P1 4 0 0 0 4 4c 4d
W2 P1 0 0 -- -- 9 5 3
W2 P3 0 0 -- -- 2 5 3
W2 P4 5 0 -- -- 4 5 3
W4 P3 0 0 -- -- 1 4 2
W4 P4 4 0 -- -- 6 4 2
W22 P1 1 0 -- -- 13 9 1
Comparison
W5 P2 2 0 -- -- 19 15 4
W5 P4 3 1 0 -- 11 15 4
W6 P3 0 0 -- -- 17 11 2
W7 P3 1 0 -- -- 11 13 1
W7 P4 1 0 -- -- 8 13 1
W7 P5 0 0 0 -- 3 13 1
W9 P1 1 1 0 -- 9 20 2
W9 P2 1 1 0 -- 7 20 2
W9 P3 4 0 0 -- 33 20 2
W9 P4 0 0 -- -- 23 20 2
W9 P5 0 0 -- -- 27 20 2
W14 P1 1 0 -- 4 7 2
W14 P2 1 0 -- 4 7 2
W15 P1 1 0 0 -- 18 18 2
W17 P1 1 0 -- -- 15 11 1
W17 P3 0 0 -- -- 11 11 1
W18 P4 1 0 -- -- 9 12 3
a Health posts with missing young infant record listed in Table 9A are not repeated in Table 9B b Among health centres and health posts that had seen sick young infants in the last three months. c Only one functional health centre sampled d Only one functional health post sampled
A13
Table 10. Health centre IMNCI staf training and staf turnover
a Among facilities with trained staf (n=111: 68 early and 43 late implementing areas) b Among facilities where trained staf left (n=22: 11 early and 11 late implementing areas), the proportion of facilities that have got replacement staf
*p value <0.05for test of diference between early and late implementers
EARLY
IMPLEMENTERS
LATE
IMPLEMENTERS
TOTAL
N=70 N=47 N=117
IMNCI training of health centre stafNumber of staf trained (mean)
Health oicers <1 <1 <1
Nurses* 2 <2 <2
Total* <3 <2 <3
IMNCI trained health centre staf turnovera
Number of staf turnover (mean) 1 1 1
Reason for leaving (%)
Transferred to another health centre 36 73 55
Promoted 18 18 18
Moved to another organisation 36 18 27
Replacement with IMNCI trained staf (%)b
Staf replaced 27 0 14
Staf proile
C. Potential of the health workers and volunteers to deliver quality CBNC service HEW knowledge
A14 Table 11. Health centre CBNC staf training and staf turnover
a Among facilities with trained staf (n=80: 49 early and 31 late implementing areas) b Among facilities where strained staf left (n=15: 10 early and 5 late implementing areas) the proportion of facilities that have got replacement staf
*p value <0.05for test of diference between early and late implementers
Table 12. PHCU CBNC staf training and turnover of HEWs
a Among facilities with trained HEWs (n=115: 70 early and 45 late implementing areas)
b Among facilities where strained staf left (n=30: 17 early and 13 late implementing areas), the proportion of facilities that have got replacement staf
c Among PHCUs where trained HEWs left proportion of facilities that have got replacement staf
EARLY
IMPLEMENTERS
LATE
IMPLEMENTERS
TOTAL
N=70 N=47 N=117
CBNC training of health centre stafNumber of staf trained (mean)
Health oicers trained <1 <1 <1
Nurses* <2 <1 1
Total <2 1 <2
CBNC trained health centre staf turnovera
Number of staf turnover (mean) <1 <1 <1
Reason for leaving (%)
Transferred to another health centre 70 80 73
Promoted 10 0 7
Moved to another organisation 10 20 13
Replacement with CBNC trained staf (%)b
Staf replaced 0 0 0
EARLY
IMPLEMENTERS
LATE
IMPLEMENTERS
TOTAL
N=70 N=47 N=117
% % %
Health post CBNC training
Number of HEWs trained (mean) 8 9 9
CBNC trained HEW turnover at PHCU levela
Number of staf turnover (mean) <1 <1 <1
Replacement with CBNC trained HEWsb
Staf replacedc 0 0 0
A15Table 13. Health post: training received by WDA leaders on MNH promotion in the last 12 months
*p value <0.05 for test of diference between early and late implementers
Figure 5. Health post: WDA satisfaction with newborn care training orientation
*p value <0.05for test of diference between early and late implementers
EARLY
IMPLEMENTERS
LATE
IMPLEMENTERS
TOTAL
N=140 N=100 N=240
% % %
Any MNH training
Among WDA who received training 83 84 83
Topics covered
Antenatal Care 97 98 98
Use of familyhealth card* 100 88 95
Educating on danger signs 97 95 96
Referring for ANC care 100 98 99
Birth preparedness plan 100 99 99
Childbirth care
Promotion of institutional delivery 98 99 99
Postnatal care
Providing home visits 96 94 95
Referring for PNC care* 99 94 97
Educating on newborn danger signs 97 93 95
Referring sick newborns 97 94 96
0
20
40
60
80
100
Late implementers
(n=84)
Early implementers
(n=116)
% o
f WD
A le
ader
s
7987
A16 Referral and service delivery linkage: referrals between WDA leader and health posts
Figure 6. Referral and reporting by WDA leadersa: pregnant woman danger signs reported to HEWs.
a Among WDA leaders that have identiied pregnant women with danger signs in the last six months
C. Potential of the health workers and volunteers to deliver quality CBNC service
HEW knowledge
Table 14. HEWs’ knowledge (unprompted): newborn general care
*p value <0.05 for test of diference between early and late implementers
0
20
40
60
80
100
Late implementers (n=33)Early implementers (n=33)
Prolonged
labour
Ofensive discharge
from birth canal
Severe abdominal
pain
Vaginal
bleeding
Swollen
hands
and face
ConvulsionsDizziness
and blurred
vision
Fever
% o
f WDA
lead
ers 67 64 68
58
3242
52 55 52 55 52 5045
64
27 27
SIGNS OF GOOD ATTACHMENT
EARLY
IMPLEMENTERS
LATE
IMPLEMENTERS
TOTAL
N=140 N=100 N=240
(%) (%) (%)
Chin touching breast* 77 61 70
Mouth open wide 80 78 79
Lower lip turned out 94 92 93
More areola showing above 86 81 84
A17
Table 15. HEWs’ knowledge (prompted): side efects of gentamycin and amoxicillin
*p value <0.05 for test of diference between early and late implementers
EARLY
IMPLEMENTERS
LATE
IMPLEMENTERS
TOTAL
N=140 (%) N=100 (%) N=240 (%)
Gentamycin and amoxicillin
Any side efect of improper use of antibiotics 47 39 44
Among those who said ‘Yes’
Possible side efect
Drug resistance 38 39 38
Injectable gentamycin
Any side efects of injectable gentamycin 34 42 37
Among those that said there are side efects
Possible side efects
Fever 55 48 52
Skin rash* 30 12 21
General anaphylactic reaction 19 21 20
Lethargy* 0 26 12
Nausea/vomiting* 17 2 10
Kidney damage 11 5 8
Nerve damage* 0 12 6
Hearing loss 4 2 3
Poor appetite 2 5 3
Weight loss 0 0 0
Any contraindication for using injectable gentamycin 16 23 20
Among those who said ‘Yes’
Reasons for contraindication
History of anaphylactic reaction 22 22 22
History of kidney/urine problem 4 4 4
History of skin reaction 3 7 5
Amoxicillin
Any side efects of amoxicillin* 14 27 20
Among those who said ‘Yes’
Possible side efects
General anaphylactic reaction 65 52 58
Any contraindication for using amoxicillin* 9 19 13
Among those who said ‘Yes’
Reasons for contraindication
History of body reaction or shock to amoxicillin 33 47 42
A18 WDA knowledge
*p value <0.05 for test of diference between early and late implementers
Figure 7. Referral and reporting by WDA leadersa: newborn danger signs reported to HEWs
a Among WDA leaders that have identiied sick newborns in the last six months
EARLY
IMPLEMENTERS
LATE
IMPLEMENTERS
TOTAL
N=131 N=83 N=214
(%) (%) (%)
Family health card images
Among users of family health card
Vitamin A capsule for mother* 30 8 22
Mother holding newborn close to body* 61 19 45
Dry cord care 8 4 7
Diarrhoea: Increasing luid intake for* 44 29 38
Reason for dry cord care* 37 55 44
Baby’s age when getting vitamin A 35 24 31
0
20
40
60
80
100
Late implementers (n=22)Early implementers (n=81)
Severe chest
in-drawing
Stopped/reduced
movement
ConvulsionsFast breathingStopped/reduced
feeding
Fever
% o
f WDA
lead
ers
80 82
5
19
6459
46
32 2923
12 14
Table 16. WDA leaders’ knowledge: family health card (job aid)
WDA practice
A19
D. Management of newborn illness
Table 17. HEW skills of CBNC case management (clinical vignettes): diarrhoea
*p value <0.05 for test of diference between early and late implementers
EARLY
IMPLEMENTERS
LATE
IMPLEMENTERS
TOTAL
N=140 N=100 N=240
(%) (%) (%)
Correct patient identiicationFull name (Baby) 69 79 73
Exact age (baby) 67 78 72
First visit or revisit 13 13 13
If revisit, then medications history 2 1 2
Correct patient assessment
Exact duration of diarrhoea* 86 67 78
Any blood in the stool 82 59 73
Sunken eyes* 73 47 62
Restless or irritability 40 35 38
Pinching abdominal skin* 74 44 61
Movement on stimulation 41 44 43
Correct classiication and treatmentClassify the neonate as having ‘some dehydration’* 84 66 76
Give ORS luids 91 87 90
Continue breast milk 88 79 84
Observe for next 4 hours* 49 24 39
Give zinc for 10 days* 84 62 75
Correct advice and follow-up
Advice
Continue breastfeed day and night, at least 10-12
times in 24 hours*
76 62 70
Breastfeed as often as the child wants* 73 41 60
Advice to report back in case of danger signs* 56 36 48
Keep the baby warm 46 43 45
Follow-up
Follow-up visit in 2 days* 76 46 63
COMMUNITY BASED NEWBORN CARE PROGRAMME
EVALUTAION AND RESOURCES
The Community Based Newborn Care (CBNC) programme is a
key milestone of the Ethiopian Health Extension Program.
The goal is to reduce newborn mortality through strengthening
the primary health care unit approach and the Health
Extension Program.
CBNC Products
LONDON SCHOOL OF HYGIENE & TROPICAL MEDICINE
The London School of Hygiene & Tropical Medicine
is a world-leading centre for research and postgraduate
education in public and global health, with 4,000 students and
more than 1,300 staf working in over 100 countries. The School is one of the highest-rated research institutions in the UK, and
was recently cited as one of the world’s top universities for
collaborative research.
www.lshtm.ac.uk
Department of Disease Control
Faculty of Infectious & Tropical Diseases
London School of Hygiene & Tropical Medicine
Keppel Street, London, WC1E 7HT, UK
w ideas.lshtm.ac.uk
@LSHTM_IDEAS
Berhanu D., Avan B.I. (2017) Community Based
Newborn Care: Quality of CBNC programme
assessment - midline evaluation report, March
2017. London: IDEAS, London School of
Hygiene & Tropical Medicine
Berhanu D., Avan B.I. (2017) Community Based
Newborn Care: Quality of CBNC programme
assessment - midline evaluation Executive
Summary, March 2017. London: IDEAS,
London School of Hygiene & Tropical Medicine
Berhanu, D., Avan, B.I., (2014) Community
Based Newborn Care: baseline report
summary, Ethiopia October 2014.
London: IDEAS, London School of Hygiene
& Tropical Medicine